Using qualitative mixed methods to study small health care organizations while maximising trustworthiness and authenticity

Background The primary health care sector delivers the majority of health care in western countries through small, community-based organizations. However, research into these healthcare organizations is limited by the time constraints and pressure facing them, and the concern by staff that research is peripheral to their work. We developed Q-RARA—Qualitative Rapid Appraisal, Rigorous Analysis—to study small, primary health care organizations in a way that is efficient, acceptable to participants and methodologically rigorous. Methods Q-RARA comprises a site visit, semi-structured interviews, structured and unstructured observations, photographs, floor plans, and social scanning data. Data were collected over the course of one day per site and the qualitative analysis was integrated and iterative. Results We found Q-RARA to be acceptable to participants and effective in collecting data on organizational function in multiple sites without disrupting the practice, while maintaining a balance between speed and trustworthiness. Conclusions The Q-RARA approach is capable of providing a richly textured, rigorous understanding of the processes of the primary care practice while also allowing researchers to develop an organizational perspective. For these reasons the approach is recommended for use in small-scale organizations both within and outside the primary health care sector.

Uptake of influenza vaccination in pregnancy amongst Australian Aboriginal and Torres Strait Islander women: A mixed-methods pilot study

Background Influenza infection during pregnancy is associated with significant morbidity and mortality. Immunisation against influenza is recommended during pregnancy in several countries but uptake of vaccine is poor. There are limited data on vaccine uptake, and the determinants of vaccination, in Australian Aboriginal and/or Torres Islander women during pregnancy. This study aimed to establish an appropriate methodology and collect pilot data on vaccine uptake and attitudes towards, and perceptions of, maternal influenza vaccination in that population in order to inform the development of larger studies. Methods A mixed-methods study comprised of a cross-sectional survey and yarning circles (focus groups) amongst Aboriginal and Torres Strait Islander women attending two primary health care services. The women were between 28 weeks gestation and less than 16 weeks post-birth. These data were supplemented by data collected in an ongoing national Australian study of maternal influenza vaccination. Aboriginal research officers collected community data and data from the yarning circles which were based on a narrative enquiry framework. Descriptive statistics were used to analyse quantitative data and thematic analyses were applied to qualitative data. Results Quantitative data were available for 53 women and seven of these women participated in the yarning circles. The proportion of women who reported receipt of an influenza vaccine during their pregnancy was 9/53. Less than half of the participants (21/53) reported they had been offered the vaccine in pregnancy. Forty-three percent reported they would get a vaccine if they became pregnant again. Qualitative data suggested perceived benefits to themselves and their infants were important factors in the decision to be vaccinated but there was insufficient information available to women to make that choice. Conclusions The rates of influenza immunisation may continue to remain low for Aboriginal and/or Torres Strait Islander women during pregnancy. Access to services and recommendations by a health care worker may be factors in the lower rates. Our findings support the need for larger studies directed at monitoring and understanding the determinants of maternal influenza vaccine uptake during pregnancy in Australian Aboriginal and Torres Strait Islander women. This research will best be achieved using methods that account for the social and cultural contexts of Aboriginal and Torres Strait Islander communities in Australia.

'As many options as there are, there are just not enough for me': Contraceptive use and barriers to access among Australian women

OBJECTIVE A comprehensive life course perspective of women's experiences in obtaining and using contraception in Australia is lacking. This paper explores free-text comments about contraception provided by women born between 1973 and 1978 who participated in the Australian Longitudinal Study on Women's Health (ALSWH). METHODS The ALSWH is a national population-based cohort study involving over 40,000 women from three age groups, who are surveyed every three years. An initial search identified 1600 comments from 690 women across five surveys from 1996 (when they were aged 18-23 years) to 2009 (31-36 years). The analysis included 305 comments from 289 participants. Factors relating to experiences of barriers to access and optimal contraceptive use were identified and explored using thematic analysis. RESULTS Five themes recurred across the five surveys as women aged: (i) side effects affecting physical and mental health; (ii) lack of information about contraception; (iii) negative experiences with health services; (iv) contraceptive failure; and (v) difficulty with accessing contraception. CONCLUSION Side effects of hormonal contraception and concerns about contraceptive failure influence women's mental and physical health. Many barriers to effective contraception persist throughout women's reproductive lives. Further research is needed into reducing barriers and minimising negative experiences, to ensure optimal contraceptive access for Australian women.

A quantitative metric to identify critical elements within seafood supply networks

A theoretical basis is required for comparing key features and critical elements in wild fisheries and aquaculture supply chains under a changing climate. Here we develop a new quantitative metric that is analogous to indices used to analyse food-webs and identify key species. The Supply Chain Index (SCI) identifies critical elements as those elements with large throughput rates, as well as greater connectivity. The sum of the scores for a supply chain provides a single metric that roughly captures both the resilience and connectedness of a supply chain. Standardised scores can facilitate cross-comparisons both under current conditions as well as under a changing climate. Identification of key elements along the supply chain may assist in informing adaptation strategies to reduce anticipated future risks posed by climate change. The SCI also provides information on the relative stability of different supply chains based on whether there is a fairly even spread in the individual scores of the top few key elements, compared with a more critical dependence on a few key individual supply chain elements. We use as a case study the Australian southern rock lobster Jasus edwardsii fishery, which is challenged by a number of climate change drivers such as impacts on recruitment and growth due to changes in large-scale and local oceanographic features. The SCI identifies airports, processors and Chinese consumers as the key elements in the lobster supply chain that merit attention to enhance stability and potentially enable growth. We also apply the index to an additional four real-world Australian commercial fishery and two aquaculture industry supply chains to highlight the utility of a systematic method for describing supply chains. Overall, our simple methodological approach to empirically-based supply chain research provides an objective method for comparing the resilience of supply chains and highlighting components that may be critical.

Missing in space: An evaluation of imputation methods for missing data in spatial analysis of risk factors for type II diabetes

Background Spatial analysis is increasingly important for identifying modifiable geographic risk factors for disease. However, spatial health data from surveys are often incomplete, ranging from missing data for only a few variables, to missing data for many variables. For spatial analyses of health outcomes, selection of an appropriate imputation method is critical in order to produce the most accurate inferences. Methods We present a cross-validation approach to select between three imputation methods for health survey data with correlated lifestyle covariates, using as a case study, type II diabetes mellitus (DM II) risk across 71 Queensland Local Government Areas (LGAs). We compare the accuracy of mean imputation to imputation using multivariate normal and conditional autoregressive prior distributions. Results Choice of imputation method depends upon the application and is not necessarily the most complex method. Mean imputation was selected as the most accurate method in this application. Conclusions Selecting an appropriate imputation method for health survey data, after accounting for spatial correlation and correlation between covariates, allows more complete analysis of geographic risk factors for disease with more confidence in the results to inform public policy decision-making.

Motivation or demotivation of health workers providing maternal health services in rural areas in Vietnam: findings from a mixed-methods study

Background Motivation is an important driver for health professionals to maintain professional competencies, continue in a workforce and contribute to work tasks. While there is some research about motivation in health workers in low to middle income countries, maternal morbidity and mortality remains high in many low and middle income countries and this can be improved by improving the quality of maternal services and the training and skills maintenance of maternal health workers. This study examines the impact of motivation on maintenance of professional competence among maternal health workers in Vietnam using mixed methods. Methods The study consisted of a survey using a self-administered questionnaire of 240 health workers in 5 districts across two Vietnamese provinces and in-depth interviews with 43 health workers and health managers at the commune, district and provincial level to explore external factors that influenced motivation. The questionnaire includes a 23 item motivation instrument based on Kenyan health context, modified for Vietnamese language and culture. Results The 240 responses represented an estimated 95% of the target sample. Multivariate analysis showed that three factors contributed to the motivation of health workers: access to training (β = -0.14, p=0.03), ability to perform key tasks (β = 0.22, p=0.001), and shift schedule (β = -0.13, p=0.05). Motivation was higher in health workers self-identifying as competent or enabled to provide more care activities. Motivation was lower in those who worked more frequent night shifts and those who had received training in the last 12 months. The interviews identified that the latter was because they felt the training was irrelevant to them, and in some cases, they do not have opportunity to practice their learnt skills. The qualitative data also showed other factors relating to service context and organisational management practices contributed to motivation. Conclusions The study demonstrates the importance of understanding the motivations of health workers and the factors that contribute to this and may contribute to more effective management of the health workforce in low and middle income countries.

Rhipicephalus (Boophilus) microplus tick in vitro feeding methods for functional (dsRNA) and vaccine candidate (antibody) screening

Rhipicephalus (Boophilus) microplus (Acari: Ixodidae) ticks cause economic losses for cattle industries throughout tropical and subtropical regions of the world estimated at $US2.5 billion annually. Lack of access to efficacious long-lasting vaccination regimes and increases in tick acaricide resistance have led to the investigation of targets for the development of novel tick vaccines and treatments. In vitro tick feeding has been used for many tick species to study the effect of new acaricides on the transmission of tick-borne pathogens. Few studies have reported the use of in vitro feeding for functional genomic studies using RNA interference and/or the effect of specific anti-tick antibodies. In particular, in vitro feeding reports for the cattle tick are limited due to its relatively short hypostome. Previously published methods were further modified to broaden optimal tick sizes/weights, feeding sources including bovine and ovine serum, optimisation of commercially available blood anti-coagulant tubes, and IgG concentrations for effective antibody delivery. Ticks are fed overnight and monitored for ∼5–6 weeks to determine egg output and success of larval emergence using a humidified incubator. Lithium-heparin blood tubes provided the most reliable anti-coagulant for bovine blood feeding compared with commercial citrated (CPDA) and EDTA tubes. Although >30 mg semi-engorged ticks fed more reliably, ticks as small as 15 mg also fed to repletion to lay viable eggs. Ticks which gained less than ∼10 mg during in vitro feeding typically did not lay eggs. One mg/ml IgG from Bm86-vaccinated cattle produced a potent anti-tick effect in vitro (83% efficacy) similar to that observed in vivo. Alternatively, feeding of dsRNA targeting Bm86 did not demonstrate anti-tick effects (11% efficacy) compared with the potent effects of ubiquitin dsRNA. This study optimises R. microplus tick in vitro feeding methods which support the development of cattle tick vaccines and treatments.

Frequency of dressing changes for central venous access devices on catheter-related infections

Background People admitted to intensive care units and those with chronic health care problems often require long-term vascular access. Central venous access devices (CVADs) are used for administering intravenous medications and blood sampling. CVADs are covered with a dressing and secured with an adhesive or adhesive tape to protect them from infection and reduce movement. Dressings are changed when they become soiled with blood or start to come away from the skin. Repeated removal and application of dressings can cause damage to the skin. The skin is an important barrier that protects the body against infection. Less frequent dressing changes may reduce skin damage, but it is unclear whether this practice affects the frequency of catheter-related infections. Objectives To assess the effect of the frequency of CVAD dressing changes on the incidence of catheter-related infections and other outcomes including pain and skin damage. Search methods In June 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trials registries for registered trials. There were no restrictions with respect to language, date of publication or study setting. Selection criteria All randomised controlled trials (RCTs) evaluating the effect of the frequency of CVAD dressing changes on the incidence of catheter-related infections on all patients in any healthcare setting. Data collection and analysis We used standard Cochrane review methodology. Two review authors independently assessed studies for inclusion, performed risk of bias assessment and data extraction. We undertook meta-analysis where appropriate or otherwise synthesised data descriptively when heterogeneous. Main results We included five RCTs (2277 participants) that compared different frequencies of CVAD dressing changes. The studies were all conducted in Europe and published between 1995 and 2009. Participants were recruited from the intensive care and cancer care departments of one children's and four adult hospitals. The studies used a variety of transparent dressings and compared a longer interval between dressing changes (5 to15 days; intervention) with a shorter interval between changes (2 to 5 days; control). In each study participants were followed up until the CVAD was removed or until discharge from ICU or hospital. - Confirmed catheter-related bloodstream infection (CRBSI) One trial randomised 995 people receiving central venous catheters to a longer or shorter interval between dressing changes and measured CRBSI. It is unclear whether there is a difference in the risk of CRBSI between people having long or short intervals between dressing changes (RR 1.42, 95% confidence interval (CI) 0.40 to 4.98) (low quality evidence). - Suspected catheter-related bloodstream infection Two trials randomised a total of 151 participants to longer or shorter dressing intervals and measured suspected CRBSI. It is unclear whether there is a difference in the risk of suspected CRBSI between people having long or short intervals between dressing changes (RR 0.70, 95% CI 0.23 to 2.10) (low quality evidence). - All cause mortality Three trials randomised a total of 896 participants to longer or shorter dressing intervals and measured all cause mortality. It is unclear whether there is a difference in the risk of death from any cause between people having long or short intervals between dressing changes (RR 1.06, 95% CI 0.90 to 1.25) (low quality evidence). - Catheter-site infection Two trials randomised a total of 371 participants to longer or shorter dressing intervals and measured catheter-site infection. It is unclear whether there is a difference in risk of catheter-site infection between people having long or short intervals between dressing changes (RR 1.07, 95% CI 0.71 to 1.63) (low quality evidence). - Skin damage One small trial (112 children) and three trials (1475 adults) measured skin damage. There was very low quality evidence for the effect of long intervals between dressing changes on skin damage compared with short intervals (children: RR of scoring ≥ 2 on the skin damage scale 0.33, 95% CI 0.16 to 0.68; data for adults not pooled). - Pain Two studies involving 193 participants measured pain. It is unclear if there is a difference between long and short interval dressing changes on pain during dressing removal (RR 0.80, 95% CI 0.46 to 1.38) (low quality evidence). Authors' conclusions The best available evidence is currently inconclusive regarding whether longer intervals between CVAD dressing changes are associated with more or less catheter-related infection, mortality or pain than shorter intervals.

Methods for Answer Extraction in Textual Question Answering

In this thesis we present and evaluate two pattern matching based methods for answer extraction in textual question answering systems. A textual question answering system is a system that seeks answers to natural language questions from unstructured text. Textual question answering systems are an important research problem because as the amount of natural language text in digital format grows all the time, the need for novel methods for pinpointing important knowledge from the vast textual databases becomes more and more urgent. We concentrate on developing methods for the automatic creation of answer extraction patterns. A new type of extraction pattern is developed also. The pattern matching based approach chosen is interesting because of its language and application independence. The answer extraction methods are developed in the framework of our own question answering system. Publicly available datasets in English are used as training and evaluation data for the methods. The techniques developed are based on the well known methods of sequence alignment and hierarchical clustering. The similarity metric used is based on edit distance. The main conclusions of the research are that answer extraction patterns consisting of the most important words of the question and of the following information extracted from the answer context: plain words, part-of-speech tags, punctuation marks and capitalization patterns, can be used in the answer extraction module of a question answering system. This type of patterns and the two new methods for generating answer extraction patterns provide average results when compared to those produced by other systems using the same dataset. However, most answer extraction methods in the question answering systems tested with the same dataset are both hand crafted and based on a system-specific and fine-grained question classification. The the new methods developed in this thesis require no manual creation of answer extraction patterns. As a source of knowledge, they require a dataset of sample questions and answers, as well as a set of text documents that contain answers to most of the questions. The question classification used in the training data is a standard one and provided already in the publicly available data.

Rethinking connectedness : an investigation into the access of teacher professional learning in regional and remote Western Australia

Many teachers working in remote and regional areas have limited access to collegial support networks. This research aimed to examine the existing strategies that were being undertaken by the Department of Education in Western Australia, to provide professional learning to teachers in regional and remote areas. It was important to establish the perceptions of teachers’ access to professional learning from those working at the coalface in geographically dispersed areas. Consequently, the possible opportunity for improving the amount and variety of professional learning, through the application of both synchronous and asynchronous technologies was proposed. The study was guided by the primary research question: “In what ways might technology be used to support professional development of regional and remote teachers in Western Australia?” Generating descriptions of current practice of professional learning along with the teacher perceptions were central to this research endeavour. The study relied on a mixed method research approach in order to attend to the research question. The data were collected in phases, referred to as an explanatory mixed methods design. Quantitative data were collected from 104 participants to provide a general picture of the research problem. To further refine this general picture, qualitative data were collected through interviews and e-interviews of 10 teachers. Participants in the study included graduate teachers, teachers who had taught more than two years, senior teachers and Level Three teachers from seven teaching districts within Western Australia. An investigation into current practice was included in this phase and technologies available to support a professional learning community over distance were documented. The final phase incorporated the formulation of a conceptual framework where a model was developed to facilitate the successful implementation of a professional learning community through the application of synchronous and asynchronous technologies. The study has identified that travel time in order to access professional development is significant and impacts on teachers’ personal time. There are limited relief teachers available in these isolated areas which impacts on the opportunities to access professional development. Teachers face inequities, in terms of promotion, because professional development is explicitly linked to promotional opportunities. Importantly, it was found that professional learning communities are valued, but are often limited by small staff numbers at the geographic locality of the school. Teachers preferred to undertake professional learning in the local context of their district, school or classroom and this professional learning must be established at the need of the individual teacher in line with the school priorities. Teachers reported they were confident in using technology and accessing professional development online if required, however, much uncertainty surrounded the use of web 2.0 technologies for this purpose. The recommendations made from the study are intended to identify how a professional learning community might be enhanced through synchronous and asynchronous technologies.

A journey access tool to facilitate mobility-related access for people with disabilities in low and middle income countries

People with disabilities (PWD) experience difficulties in accessing the transport system (including both infrastructure and services) to meet their needs for health care, employment and other activities. Our research shows that lack of access to the journeys needed for these purposes is a more significant barrier in low and middle income countries than in high income countries, and results in inadequate health care, rehabilitation and access to education and employment. At the same time, the existing transport system in low and middle income countries presents much higher road crash risks than in high income countries. By combining the principles and methods of Road Safety Audit and disability access, and adapting these Western approaches to a low/middle income country context, we have worked with Handicap International Cambodia to develop a Journey Access Tool (JAT) for use by disabled peoples’ organisations (DPOs), people with a disability and other key stakeholders. A key element of the approach is that it involves the participation of PWD on the journeys that they need to take, and it identifies infrastructure and service improvements that should be prioritised in order to facilitate access to these journeys. The JAT has been piloted in Cambodia with a range of PWD. This presentation will outline the design of the JAT and the results of the pilot studies. The information gained thus far strongly suggests that the JAT is a valuable and cost-effective approach that can be used by DPOs and professionals to identify barriers to access and prioritise the steps needed to address them.

On Two-User Gaussian Multiple Access Channels With Finite Input Constellations

Constellation Constrained (CC) capacity regions of two-user Single-Input Single-Output (SISO) Gaussian Multiple Access Channels (GMAC) are computed for several Non-Orthogonal Multiple Access schemes (NO-MA) and Orthogonal Multiple Access schemes (O-MA). For NO-MA schemes, a metric is proposed to compute the angle(s) of rotation between the input constellations such that the CC capacity regions are maximally enlarged. Further, code pairs based on Trellis Coded Modulation (TCM) are designed with PSK constellation pairs and PAM constellation pairs such that any rate pair within the CC capacity region can be approached. Such a NO-MA scheme which employs CC capacity approaching trellis codes is referred to as Trellis Coded Multiple Access (TCMA). Then, CC capacity regions of O-MA schemes such as Frequency Division Multiple Access (FDMA) and Time Division Multiple Access (TDMA) are also computed and it is shown that, unlike the Gaussian distributed continuous constellations case, the CC capacity regions with FDMA are strictly contained inside the CC capacity regions with TCMA. Hence, for finite constellations, a NO-MA scheme such as TCMA is better than FDMA and TDMA which makes NO-MA schemes worth pursuing in practice for two-user GMAC. Then, the idea of introducing rotations between the input constellations is used to construct Space-Time Block Code (STBC) pairs for two-user Multiple-Input Single-Output (MISO) fading MAC. The proposed STBCs are shown to have reduced Maximum Likelihood (ML) decoding complexity and information-losslessness property. Finally, STBC pairs with reduced sphere decoding complexity are proposed for two-user Multiple-Input Multiple-Output (MIMO) fading MAC.

Comparison of the degree of creativity in the design outcomes using different design methods

This work analyses the influence of several design methods on the degree of creativity of the design outcome. A design experiment has been carried out in which the participants were divided into four teams of three members, and each team was asked to work applying different design methods. The selected methods were Brainstorming, Functional Analysis, and SCAMPER method. The `degree of creativity' of each design outcome is assessed by means of a questionnaire offered to a number of experts and by means of three different metrics: the metric of Moss, the metric of Sarkar and Chakrabarti, and the evaluation of innovative potential. The three metrics share the property of measuring the creativity as a combination of the degree of novelty and the degree of usefulness. The results show that Brainstorming provides more creative outcomes than when no method is applied, while this is not proved for SCAMPER and Functional Analysis.

Optical microscopy methods for understanding learning and memory

Structural dynamics of dendritic spines is one of the key correlative measures of synaptic plasticity for encoding short-term and long-term memory. Optical studies of structural changes in brain tissue using confocal microscopy face difficulties of scattering. This results in low signal-to-noise ratio and thus limiting the imaging depth to few tens of microns. Multiphoton microscopy (MpM) overcomes this limitation by using low-energy photons to cause localized excitation and achieve high resolution in all three dimensions. Multiple low-energy photons with longer wavelengths minimize scattering and allow access to deeper brain regions at several hundred microns. In this article, we provide a basic understanding of the physical phenomena that give MpM an edge over conventional microscopy. Further, we highlight a few of the key studies in the field of learning and memory which would not have been possible without the advent of MpM.

Novel Transmit Precoding Methods for Rayleigh Fading Multiuser TDD-MIMO Systems With CSIT and No CSIR

In this paper, we present novel precoding methods for multiuser Rayleigh fading multiple-input-multiple-output (MIMO) systems when channel state information (CSI) is available at the transmitter (CSIT) but not at the receiver (CSIR). Such a scenario is relevant, for example, in time-division duplex (TDD) MIMO communications, where, due to channel reciprocity, CSIT can be directly acquired by sending a training sequence from the receiver to the transmitter(s). We propose three transmit precoding schemes that convert the fading MIMO channel into a fixed-gain additive white Gaussian noise (AWGN) channel while satisfying an average power constraint. We also extend one of the precoding schemes to the multiuser Rayleigh fading multiple-access channel (MAC), broadcast channel (BC), and interference channel (IC). The proposed schemes convert the fading MIMO channel into fixed-gain parallel AWGN channels in all three cases. Hence, they achieve an infinite diversity order, which is in sharp contrast to schemes based on perfect CSIR and no CSIT, which, at best, achieve a finite diversity order. Further, we show that a polynomial diversity order is retained, even in the presence of channel estimation errors at the transmitter. Monte Carlo simulations illustrate the bit error rate (BER) performance obtainable from the proposed precoding scheme compared with existing transmit precoding schemes.