A Guide to Field Notes for Qualitative Research: Context and Conversation

HIV understanding, experiences and perceptions of HIV-positive men who have sex with men in Amazonian Peru: a qualitative study

BACKGROUND

HIV-related incidence and mortality is increasing across Peru, with highest mortality rates recorded in the Amazonian region of Loreto. This epidemic is concentrated in men who have sex with men, a population with 14% HIV treatment adherence despite free national provision. This study investigates barriers and facilitators to following healthcare advice through experiences and perceptions of HIV-positive men who have sex with men and healthcare professionals in Loreto.

METHODS

Twenty qualitative interviews with HIV-positive men who have sex with men and one focus group with HIV-specialist healthcare professionals were conducted in Loreto, January-February 2019. Interviews were transcribed per verbatim. Thematic content analysis and deviant case analysis were used.

RESULTS

A culture of isolation and discrimination was identified, propagated by poor public knowledge surrounding HIV transmission and treatment. Employment potential was hampered and 7/20 patients had suicidal thoughts post-diagnosis. Barriers to care included: shame, depression, travel cost/times, a preference for traditional plant-based medicine and side-effects of antiretroviral therapy. Facilitators included: education, family and clinic support, disease acceptance and lifestyle changes.

CONCLUSION

More effective, focussed community education and workplace discrimination investigations are recommended to reduce stigma and increase adherence to treatment in this population.

Perceived Health Impacts of Watershed Development Projects in Southern India: A Qualitative Study

Watershed development (WSD) projects—planned for over 100 million ha in semi-arid areas of India—should enhance soil and water conservation, agricultural productivity and local livelihood, and contribute to better nutrition and health. Yet, little is known about the health impacts of WSD projects, especially on nutrition, vector breeding, water quality and the distribution of impacts. We conducted a qualitative study to deepen the understanding on perceived health impacts of completed WSD projects in four villages of Kolar district, India. Field data collection comprised: (i) focus group discussions with local women (n = 2); (ii) interviews (n = 40; purposive sampling) with farmers and labourers, project employees and health workers; and (iii) transect walks. Our main findings were impacts perceived on nutrition (e.g., food security through better crop survival, higher milk consumption from livestock, alongside increased pesticide exposure with expanded agriculture), potential for mosquito larval breeding (e.g., more breeding sites) and through opportunistic activities (e.g., reduced mental stress due to improved water access). Impacts perceived varied between participant categories (e.g., better nutrition in woman-headed households from livelihood support). Some of these findings, e.g., potential negative health implications, have previously not been reported. Our observations informed a health impact assessment of a planned WSD project, and may encourage implementing agencies to incorporate health considerations to enhance positive and mitigate negative health impacts in future WSD projects.

Feeling safe with patient-controlled admissions: A grounded theory study of the mental health patients' experiences

AIM

To develop a grounded theory of the patients' experiences with patient-controlled admission.

BACKGROUND

Research indicates a potential for involving patients in mental health care, but there is a need to develop and investigate new approaches in health services. Patient-controlled admission is an option for patients with severe mental disorders to refer themselves for a brief hospital admission when needed and thus avoid the usual admission procedure.

DESIGN

Classic grounded theory with generation of a theory based on the constant comparative method for data collection and analysis.

METHODS

Field observations and interviews with 26 mental health patients. The COREQ checklist was followed.

RESULTS

We found that patient-controlled admission induced safety by providing faster access to help and thus preventing further deterioration of symptoms. Being self-determined, achieving calmness and receiving care with support and guidance from professionals during admission contributed to the sense of safety. The familiarity with the mental health professionals in their related units supported the patients in managing their situation. On the other hand, feelings of being overlooked by the professionals and experiencing uncertainty could undermine patients' feeling of safety.

CONCLUSIONS

We demonstrate that safety is a focal point for patients when receiving help and support in mental health care. Patient-controlled admission can induce a feeling of safety both at the hospital and at home. Patients' self-determination is strengthened, and brief admissions give them an opportunity to handle what they are currently struggling with. Professionals can support patients in this, but their actions can also reduce patients' feeling of safety.

RELEVANCE TO CLINICAL PRACTICE

Patient involvement can be introduced in psychiatry, and even severely ill patients seem to be able to assess their own condition. Feasibility may, however, be associated with the attitude and behaviour of the professionals in clinical practice.

Mothers Who Take Care of Children with Disabilities in Rural Areas of a Spanish Region

The purpose of this research is to describe how the mothers of children with disabilities in rural areas of Extremadura perceive care tasks and the subjective impact that these tasks have on their daily life and health, as well as the subjective assessment that these mothers make of the benefits and services of the Spanish welfare policy. An interpretative paradigm was selected, using a qualitative approach and a phenomenological design. Twelve mothers were included. Data were collected through semi-structured interviews. A discourse analysis of the narrative information was performed using open, axial, and selective coding processes and the constant comparative method. Three topics have been extracted from the findings of the analysis: (1) extensive care responsibilities, (2) impacts upon well-being and daily life, and (3) resources that “barely” help. The care tasks performed by mothers of children with disabilities in rural areas have an enormous impact on their daily life and health. This involvement in caregiving generates a significant occupational imbalance which has an impact on their mental health, and which causes economic and social problems.

Physical activity in paid work time for desk-based employees: a qualitative study of employers' and employees' perspectives

Background

Poor physical and mental health of employees create significant problems in the workplace. Physical activity (PA) has been shown as an effective strategy for preventing and treating numerous physical and mental health issues as well as work performance outcomes. However, there are many barriers to taking part in PA (such as lack of time) with participation rates typically low. Providing PA in paid work time might be a way to overcome these issues, yet employers’ and employees’ opinions of this concept are unknown. The aim of this study was to explore employee and employer perspectives of PA in paid work time.

Methods

Workplaces were recruited through existing contacts on the research team. Focus groups and interviews were conducted with employees and managers at one University and two executive non-departmental public bodies in central Scotland with mainly desk-based employees. Both managers and employees were involved to gain perspectives throughout the organisational hierarchy and were interviewed separately to reduce social desirability bias. All discussions were digitally recorded and transcribed verbatim. Data were analysed thematically for both managers and employees but due to significant overlap in themes between the groups, these are reported together in the results.

Results

Three out of five organisations approached took part in this qualitative study. Two individual interviews were held with strategic managers, five focus groups with middle managers (n = 16) and nine with employees (n = 45). Benefits were anticipated by managers and employees for both employees themselves and the organisation and included improved mental health, productivity and more favourable perceptions of the employer. Despite these widely acknowledged benefits, significant barriers were identified and included the structure and nature of the working day (high workload, front line job requirements), workplace culture and norms (resentment from colleagues, no break culture) and organisational concerns (cost of lost time, public perceptions).

Conclusion

This study suggests that there are significant barriers to PA in paid work time. Whilst numerous anticipated benefits were conveyed by both employees and managers, PA in paid work time is unlikely to become common place until changes in attitudes and the culture towards movement at work occur.

Understanding the Concept of Neighbourhood in Kigali City, Rwanda

Though the relevance of the concept of neighbourhood in both research and policy oriented circles is unquestionable, the concept remains contested and fluid, making its operationalisation a daunting task, particularly in practice. This study explores how the concept of neighbourhood has been operationalised in Kigali city and how the neighbourhood boundaries and typologies are defined. The paper dwells on the review of relevant literature, interviews with 25 practitioners and field observations. It is argued that neighbourhood conceptualisation in Kigali is both theory—it bears the common aspects of neighbourhood definitions—and practice driven, reflecting modernity and context. On the one hand, modernity suggests the desire of planning authorities to follow contemporary planning practices. Context, on the other hand, reflects the desire to tailor local policies to country specific challenges. While boundaries follow subjective, administrative and physical models, typologies tend to be overly physical, focusing mainly on housing structures. The study identified three conventional neighbourhood typologies—planned, informal and mixed types. Given the predominance of informal and mixed neighbourhoods, this study further argues that such areas form the ‘bedroom’ and ‘transit point’ for most lower- and middle-class workers, in addition to serving as a ‘laboratory’ for testing various social interventions. The study recommends a well-serviced mixed classification typology to foster a strong sense of belongingness.

Flying into the hurricane: A case study of UAV use in damage assessment during the 2017 hurricanes in Texas and Florida

Unmanned aerial vehicles (UAVs) or drones have been used by disaster relief organizations in the United States since 2005. However, their place in the disaster response ecosystem—the standardization, utility, ethical, and legal challenges of drone use—remains largely unstudied. This case series describes how UAVs were used by two teams of responders for damage assessment purposes during the 2017 southeastern US Hurricanes Harvey and Irma. Data streams ranged from social media, direct observation, participant-observation and semi-directed interviews. Qualitative analysis was performed for thematic content derived from field observation and from post-hoc interviews. Outcomes of the qualitative analysis emphasize the barriers to deploying drones in the disaster context, their tactical implementation, programmatic integration, and ethical and legal challenges. These observations lay the groundwork for both future research on the utilization of drones and the prudent and ethical implementation of programs that employ drones in post-disaster settings.

Hermeneutic observational studies: describing a method

There is a need to develop and use research observations in the clinical field, primarily to gain insight into and assess evidence of what comprises caring in a real-life situation and confirm what is actually taking place. In addition, assessments lead to a new and different understanding of what caring constitutes, thereby enabling the identification of what kind of care is being provided and is required. Such observations also enable the observer to perceive and verbalise caring. There are ongoing discussions, specifically in Nordic countries, on how to use caring science-based observations as a means of collecting and interpreting qualitative data through the application of a hermeneutic approach, which constitutes describing what has been seen and reporting on it by way of ethical obligation. This article contributes to the debate through the provision of additional content and by reflecting on the development and usability of hermeneutical research observations from a method and methodological perspective, thereby refining previous ideas and extending previous assumptions. The primary study objective was to report on the experience of utilising observations as a single data collection method for hermeneutic research with the aim of evaluating the interplay between intensive care unit (ICU) patients and their next of kin. A secondary objective was to highlight the impact of preknowledge and preunderstanding on the interpretation process. An intensive care context was assessed as the most appropriate, as the majority of patients are unable to engage in verbal narratives during ongoing treatment and care. The benefits of employing hermeneutic observation as well as interpretation and preunderstanding from a caring science perspective are considered.

Advanced practice nurses in primary care in Switzerland: an analysis of interprofessional collaboration

BACKGROUND

The increase in the number of chronically ill patients due to ageing is calling existing models of primary care (PC) into question. New care models have recently been implemented in Swiss PC and involve interprofessional teams. This paper aimed to investigate the practice of interprofessional collaboration between advanced practice nurses, registered nurses, and medical practice assistants within new models of PC in Switzerland using the National Interprofessional Competency Framework.

METHODS

An ethnographic design comprising semi-structured interviews and non-participant observations was conducted. Sixteen interviews were conducted with care providers at their PC practice. Interviewees included four advanced practice nurses, two registered nurses, six medical practice assistants, and four general practitioners. Nine other health professionals were subsequently observed in their practice. Interviews and observations were conducted by the first author from February to April 2019.

RESULTS

Our analysis of interview and observational data confirmed that role clarification, team functioning, collaborative leadership, interprofessional conflict resolution, patient-centered care, and interprofessional communication have a significant influence on the interprofessional collaboration among health professionals in Swiss PC. Among these domains, role clarification and team functioning were the most frequently raised issues. Both were found to have the potential to negatively influence and, therefore, hinder efficient interprofessional collaboration within PC.

CONCLUSION

From the analysis, it emerged that role clarification is crucial for effective interprofessional collaboration within new care delivery models in the Swiss PC context. Our study results may inform international health policymakers and practitioners about six important domains of interprofessional care when implementing new care models. Practical experience with new models of care involving advanced practice nurses and medical practice assistants may also influence the regulation of the scope of practice of these health professionals in Switzerland.

Advanced practice nurses, registered nurses and medical practice assistants in new care models in Swiss primary care: a focused ethnography of their professional roles

OBJECTIVES

We aimed to analyse roles and tasks of advanced practice nurses (APNs), registered nurses (RNs) without advanced practice education and medical practice assistants (MPAs) with regard to chronic care in Swiss primary care (PC). The objective of this study was to explore the potential of new care models, involving these health professionals, which could meet changing future healthcare needs.

DESIGN

An ethnographic design comprising semi-structured interviews and non-participant observations was conducted.

SETTING

Health professionals who worked in 10 primary care practices in the German-speaking part of Switzerland were included in the study.

PARTICIPANTS

In total, 16 interviews were conducted with four APNs, six MPAs, two RNs and four general practitioners (GPs). Nine of the health professionals were subsequently observed in their primary care practice.

RESULTS

APNs and MPAs were both involved in chronic care in the PC practice. While APNs cared for older, multimorbid patients with more complex needs, MPAs were involved in counselling of younger patients with chronic disease such as type 2 diabetes. Additionally, APNs were involved in many home visits and visits in elderly peoples - and nursing homes. APNs worked with a high degree of autonomy while MPAs had worked mostly in delegation. Task division between GPs and APNs or MPAs was not clear in every case yet.

CONCLUSIONS

APNs and MPAs have a high potential to contribute to optimal care in new care models, which address needs of the elderly population. The experience from our sample may inform international health policymakers and practitioners about the tasks and responsibilities those health professionals can take over in PC when implementing new models of care. The practical experience with new models of care involving APNs and MPAs may also influence the future regulation with regard to the scope of practice of these health professionals in Switzerland.

'A different kind of space': Mixed methods evaluation of facilitated reflective practice groups for nurses in an acute inpatient mental health unit

Despite recognising the value of reflective practice, there are challenges in implementation of clinical supervision for nurses. This study reports on the implementation of Reflective Practice Groups for nurses in an acute inpatient mental health setting as a means of introducing nurses to reflective practice. A mixed-methods approach explored participant and facilitator experiences through session evaluation questionnaires, facilitator field notes, and interviews with participants. Findings demonstrate challenges in implementing Reflective Practice Groups however the perceived benefits suggest promise in using Reflective Practice Groups to engage busy nurses in facilitated reflection with an aim to transition to reflective clinical supervision.

We Can Quit2 (WCQ2): a community-based intervention on smoking cessation for women living in disadvantaged areas of Ireland-study protocol for a pilot cluster randomised controlled trial

BACKGROUND

Tobacco use is the leading cause of preventable death in Ireland with almost 6000 smokers dying each year from smoking-related diseases. The 'We Can Quit2' (WCQ2) study is a pilot pragmatic two-arm, parallel-group, cluster randomised trial that aims to explore the feasibility and acceptability of trial processes including recruitment and to estimate parameters to inform sample size estimates needed for an effectiveness trial. This future trial will assess the effectiveness of a community-based smoking cessation intervention for women living in disadvantaged areas on short- and medium-term cessation rates.

METHODS/DESIGN

Four matched pairs of districts (eight clusters) selected by area level of deprivation, geographical proximity, and eligibility for free medical services will be randomised to receive either WCQ (behavioural support + access to Nicotine Replacement Therapy (NRT)) delivered over 12 weeks by trained Community Facilitators (CFs) or to a form of usual care, a one-to-one smoking cessation service delivered by Smoking Cessation Officers from Ireland's national health service, the Health Service Executive (HSE). Within each cluster, 24-25 women will be recruited (97 per arm; 194 in total) in 4 phases with consent obtained prior to cluster randomisation. The outcome measures will assess feasibility and acceptability of trial processes, including randomisation. Outcome data for a future definitive intervention (biochemically validated smoking abstinence) will be collected at end of programme (12 weeks) and at 6 months. WCQ2 has an embedded process evaluation using both qualitative and quantitative methods. This will be conducted (semi-structured client and CF interviews, intervention delivery checklist, and diary) to explore acceptability of trial processes, intervention fidelity, trial context, and implementation. Trial processes will be assessed against domains of the PRECIS-2 wheel to inform a future definitive trial design.

DISCUSSION

Data from this pilot trial will inform the design and sample size for a full cluster randomised trial to determine the effectiveness of an intervention tailored to disadvantaged women in improving smoking cessation rates. It will provide transferable learning on the systems and implementation strategies needed to support effective design of future pragmatic community-based trials which address health promotion interventions for women in disadvantaged communities.

TRIAL REGISTRATION

Concurrent to publication. Controlled trials ISRCTN74721694.

Challenges in accessing research sites in Ghana: a research note

Purpose

Despite the crucial role of gaining access for successful research in social and management studies, very little has been written on issues and challenges associated with gaining access particularly in an undeveloped research context such as Ghana. The purpose of this paper is to share the experience with other researchers and practitioners for them to recognise the common challenges associated with gaining access to research sites and the significance of critical reflection and reflexivity on how a researcher’s positionality affects knowledge production. The paper emphasises the need for researchers to appreciate the taken-for-granted interactions that can contribute to critical thinking about identities and reflexivity in research. The paper adds to the paucity of voices particularly overseas students and researchers returning home (to country of origin) from Euro-American institutions to carry out field research.

Design/methodology/approach

The paper draws on the field notes relating to the PhD fieldwork experiences in accessing subsidiaries of western multinational enterprises in Ghana. The author discussed how gatekeepers hindered access to key organisational members and the need to identify helpful networks through snowballing in order to access organisations and participants.

Findings

Considerable challenges such as denial of access, physical and psychological distress were encountered in the process of accessing organisations which often led to abandoning certain sites for others, even though those originally chosen were potentially rich sources of information. Also, positionality and the manner in which a researcher is perceived by participants certainly influence the knowledge one produces. Sufficient time is needed to negotiate and build relationships of trust with gatekeepers, which often resulted in delays in data collection. In this present study, gatekeepers often denied, limited or delayed access to potential participants and sites despite institutional ethical approval.

Practical implications

The experiences highlighted in this paper can serve as a toolkit for qualitative researchers interested in conducting research in Ghana with regard to what to expect and how to manoeuvre through in the field.

Originality/value

The paper contributes to the dearth of the methodology literature on issues relating to challenges to access, positionality, insider/outsider status of the researcher and their influences on knowledge production in an under-researched context, Ghana.

The 3 Cs of Content, Context, and Concepts: A Practical Approach to Recording Unstructured Field Observations

Most primary care researchers lack a practical approach for including field observations in their studies, even though observations can offer important qualitative insights and provide a mechanism for documenting behaviors, events, and unexpected occurrences. We present an overview of unstructured field observations as a qualitative research method for analyzing material surroundings and social interactions. We then detail a practical approach to collecting and recording observational data through a "3 Cs" template of content, context, and concepts. To demonstrate how this method works in practice, we provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar.

'It's a tough decision': a qualitative study of proxy decision-making for research involving adults who lack capacity to consent in UK

BACKGROUND

Research into dementia and other conditions connected with cognitive impairments is essential but conducting research with populations who lack capacity to provide consent involves a number of ethical, legal and practical challenges. In England and Wales, family members can act as a consultee or legal representative on behalf of someone who lacks capacity. However, there is a paucity of research about how family members make decisions concerning research participation.

OBJECTIVE

To explore family members' experiences of proxy decision-making for research. Understanding how proxy decisions are made could lead to interventions to support greater inclusion of individuals in research who have impaired decision-making capacity.

METHODS

Semi-structured interviews were conducted with a purposive sample of 17 family members who had experience as a proxy for making decisions about participation in research, including those who had agreed to participation and those who declined. Thematic analysis was used to examine experiences and generate findings for research practice and to develop future supportive interventions.

RESULTS

Proxy decision-making is highly contextualised. Proxies balance a number of factors when deciding about research participation, including the person's values and preferences, within the specific context of the study, and the practicalities of being involved. Proxies use these factors to construct a decision that is authentic to the person they care for.

CONCLUSIONS

Proxy decision-making for research is a complex process with inter-woven layers of decision-making. Decisions can be problematic for some proxies who may benefit from decision support to make an informed decision about research participation on behalf of a family member.

The experience of patients and family caregivers in managing pneumoconiosis in the family context: A study protocol

AIM

This study aims to explore the illness experience and needs of patients with pneumoconiosis and the caregiving experience of their respective family caregivers.

DESIGN

This is an exploratory qualitative study.

METHODS

Participants will be recruited during the annual patient interview with purposive sampling. Those with a confirmed diagnosis of pneumoconiosis for at least 1 year will be eligible. Patients with different levels of physical dependency will be recruited. The respective family caregivers of these patients, who are ≥21 years of age, assuming the role as primary caregivers of a pneumoconiosis patient will also be invited to join. In-depth interviews will be conducted in patients' home separately for patients and their caregivers and a home environment assessment will also be undertaken. The interview data will be transcribed verbatim, managed with the software NVivo 11 and analysed with content analysis. The ethical approval has obtained, and this study is supported by a research grant from the Pneumoconiosis Compensation Fund Board of Hong Kong on 14 August 2018.

DISCUSSION

This study will advance the knowledge on how pneumoconiosis patients and their family caregivers manage the disease in the family context. The findings of this study can inform the development of a family-oriented care model to support the pneumoconiosis patients and their family caregivers to manage this condition better.

IMPACT STATEMENT

Pneumoconiosis is the most common type of occupational lung disease in the Chinese population. These patients require long-term comprehensive services and support to assist their disease self-management. However, little is known about how these patients and their family caregivers manage the disease in the family context. The current study addresses this gap by exploring patients' illness experience and their family members' caregiving experience, which is timely to inform the design of family-oriented model of care to support this clinical cohort.

CLINICAL TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov (NCT04022902).

"Some of us, we don't know where we're going to be tomorrow." Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco

Transgender women (TW) are disproportionately affected by HIV. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce TW's vulnerability to HIV, but PrEP uptake has been limited among TW. To explore barriers to PrEP uptake, the study team conducted two semi-structured focus groups with TW in San Francisco at risk for HIV acquisition. A within-case, across-case approach was used to code and analyze emerging themes. Focus group participants were racially and ethnically diverse. A few participants in both groups had heard of PrEP, but some had not. Several said that their health care providers had not told them about PrEP. Participants in both groups had questions about side effects. They expressed medical mistrust and said poverty is an important context for their lives. They described a need for gender affirming health care services and raised concerns about interactions of PrEP with feminizing hormones. Information about side effects and interactions between gender affirming hormones and PrEP need to be explicitly addressed in PrEP education campaigns focusing on TW. Health care institutions and health departments should train clinical staff how to provide affirming care. Gender identity nondiscrimination laws and policies could improve transgender people's ability to earn a living and access health care.

Increasing cultural awareness: qualitative study of nurses' perceptions about cultural competence training

BACKGROUND

Nowadays, healthcare professionals worldwide deliver care for increasing numbers of culturally and linguistically diverse patients. The importance of cultural competence is evident in terms of the quality of healthcare, and more knowledge is needed about different educational models and approaches that aim to increase cultural competence. This study examines the perceptions of nurses about the content and utility of cultural competence training that focuses on increasing awareness of one's own cultural features.

METHODS

The training was conducted at one primary care hospital in southern Finland. Participants were registered nurses (n = 14) and practical nurses (n = 6) from different hospital units. Four 4-h training sessions-including lectures, discussions and short web-based learning tasks-were arranged during a four-week period. Semi-structured, small group interviews were conducted with 10 participants to examine their perceptions about the content and utility of the training. Qualitative content analysis with a conventional approach was used to analyse the data.

RESULTS

Perceptions about the training were divided into three main categories: general utility of the training, personal utility of the training, and utility of the training for patients. General utility pertains to the general approach that the training provided on cross-cultural care, the possibility to initiate an open discussion, and the opportunity to improve current practices. Personal utility pertains to the opportunity to become aware of one's own cultural features, to change one's way of thinking, to obtain a new perspective on one's own communication practices and to receive justification for carrying out particular workable practices. Utility for patients pertains to fostering better awareness and acknowledgement of patients' differing cultural features and an increased respect in healthcare delivery. Additionally, the quality of the training was highlighted, and suggestions for improvement were offered.

CONCLUSION

Training that increases healthcare professionals' awareness of their own cultural features was perceived as useful and thought-provoking. Increased awareness might facilitate the communication between healthcare professionals and patients, which is a crucial component of quality healthcare. It seems that in the future, training opportunities that allow larger groups to participate are needed, regardless of the time and place, and utilising the potential of e-learning should be considered.

A photovoice study on the bereavement experience of mothers after the death of a child

This study explored the bereavement experience of mothers after losing a child to cancer in Korea, using photovoice. The mothers took photos reflecting five subject areas they selected: (a) if I had one more day with my child, (b) memories with my child, (c) dreaming of my child's healthy future, (d) what gave me strength, and (e) fulfilling my child's wishes for the future. The findings show that mothers who lost a child to cancer need bereavement care to promote well-being. This study can help pediatric oncology providers develop bereavement interventions that address parental grief and improve quality of life.

Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units

BACKGROUND

Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%.

PURPOSE

This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC.

METHODS

A descriptive cross-sectional correlational study was completed among US quality improvement-focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs.

RESULTS

NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = -0.26, P = .049), as was colostrum for oral care (Rho = -0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003).

IMPLICATIONS FOR PRACTICE

Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount.

IMPLICATIONS FOR RESEARCH

Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.

Educational impact of assessment on medical students' learning at Tehran University of Medical Sciences: a qualitative study

OBJECTIVES

It has been shown that assessment strongly affects students' performance. A deeper insight needs to be gained into the interplay of assessment and learning. The aim of the current study was to develop a model to explain the educational impact of assessments on students' learning, before, during and after the test.

DESIGN

This study used semistructured interviews, focus group discussions and observation and collection of field notes. A qualitative methodology using the grounded theory data analysis approach was then used to generate an explanation of the process of how assessment impacts students' learning.

SETTING

School of Medicine, Tehran University of Medical Sciences.

PARTICIPANTS

Participants were medical students and teachers with first-hand experience or expertise in assessment as well as their willingness to participate in the study. Fifteen people (eight medical students, seven faculty members) were interviewed. One focus group discussion (with five students) was held.

RESULTS

The extracted concepts from our study were classified into four main categories. These categories include elements of the assessment programme which affect learning, the mechanism through which they exert their effects, contextual factors and the impact they have on learning. These elements and their interplay occur within an environment with its antecedent characteristics.

CONCLUSIONS

This study suggested a model for understanding the elements of the assessment which, within the context, affect learning, the mechanisms through which they impart their effects and the final outcomes obtained.

Therapy the Natural Way: A Realist Exploration of the Wilderness Therapy Treatment Process in Adolescent Mental Health Care in Norway

Wilderness therapy has the potential to meet the specific needs of the current adolescent population by providing a rather unique outdoor group treatment. Wilderness therapy is not a new approach to mental health treatment, but its theoretical basis is not yet clearly delineated, in part because of the diversity found across programs and contexts. This article presents a critical realist exploration of a wilderness therapy program that was recently implemented as part of adolescent mental health services in Southern Norway. In this study, we combine fieldwork and interviews for an in-depth investigation of the treatment process, where the objective was to acquire a deeper understanding of the opportunities that arise in the wilderness therapy setting. The therapeutic mechanisms and influential contextual premises found across the ecological, physical, and psychosocial factors of this multidimensional approach to treatment are presented, and their underlying conditions are briefly discussed.

Understanding Cellular Respiration through Simulation Using Lego® as a Concrete Dynamic Model

Out of all the complex systems in science education curricula, cellular respiration is considered to be one of the most complex and abstract processes. Students are known to have low interest and difficulties in conceptual understanding of cellular respiration which provides a challenge for teaching and learning. In this study, we took literature about modelling and teaching and learning cellular respiration as a starting point for the design of a concrete dynamic model in which students (n = 126) use Lego® to simulate the process of cellular respiration. Students used the simulation embedded in the context of finding the efficiency of a sediment battery as a future source of green energy and we tested the effects on conceptual learning and situational interest in an experimental study. Results on conceptual learning show that both experimental and control groups had comparable results in the test. The questions that students in the experimental group asked during enactment, however, gave notice of a focus on both isolated component parts as well as modes of organization at higher organizational levels which is linked to how biologists mechanistically understand complex systems. Both groups report a similar high measure to which the topic is meaningful in real life (situational interest value), whereas the enjoyment (situational interest feeling) was significantly increased in the experimental group. Furthermore, students report specific advantages (e.g., I now understand that one acid chemically changes into another and they do not just transfer atoms) and disadvantages (e.g., time issues).

Validity in qualitative health education research

Validity has had a contentious history in qualitative research. This is so for qualitative health education research as well. Establishing and writing about validity in qualitative research can be a challenging task as there are numerous viewpoints on what constitutes validity and varied nomenclature, such as trustworthiness, credibility, dependability, confirmability, authenticity, rigor, plausibility, goodness, soundness, transferability, and quality assessment. However, there is general agreement that establishing trust in the inferences that are made is necessary. Validity is dependent on the purpose and context of the research, and refers to conclusions that are based on particular methods used to address validity threats that are pertinent to the particular research. This article should help researchers distinguish among a variety of validation checks for a contextualized approach to establishing validity and apply these checks to their own qualitative health education research.

Content validation of Mental Health Literacy Scale (MHLS) for primary health care workers in South Africa and Zambia ─ a heterogeneous expert panel method

Background: The lack of public knowledge and the burden caused by mental-health issues' effect on developing and implementing adequate mental-health care for young and adolescent in low- and middle-income countries (LMIC). Primary health care could be the key in facing the challenge, but it suffers from insufficient resources and poor mental health literacy. This study's aim was to adapt the content validity of the Mental Health Literacy Scale (MHLS) developed by O'Connor & Casey (2015) with researchers and primary health-care workers in low- and middle-income contexts in South Africa (SA) and in Zambia.Objectives: The study population comprised two expert panels (N = 21); Clinical Experts (CE) (n = 10) from Lusaka, Zambia and Professional Research Experts (PE) (n = 11) from the MEGA project management team were recruited to the study.Methods: MHLS was validated in a South African and a Zambian context using a heterogeneous expert-panel method. Participants were asked to rate the 35 MHLS items on a 4-point scale with 1 as not relevant and 4 as very relevant After the rating, all 35 MHLS items were carefully discussed by the expert panel and evaluated according their relevance. The data were analyzed using an item-level content validity index (I-CVI) and narrative and thematic analyses.Results: All 35 items ranked by the PREs met the cutoff criteria (≥0.8), and ten (n = 10) items were seen as relevant by CE when calculating I-CVIs. Based on the results of ratings and discussion, a group of sixteen (n = 16) of all items (n = 35) were retained as original without reviewing. A total of nineteen (n = 19) items were reviewed.Conclusion: This study found the MHLS to have sufficient validity in LMICs' context but also recognized a gap between professional researchers' and clinical workers' knowledge and attitudes related to mental health.

Spousal bereavement after fibrotic interstitial lung disease: A qualitative study

INTRODUCTION

Fibrotic interstitial lung disease (f-ILD) comprises a group of diseases with lung scarring and reduced life expectancy. The short time from diagnosis to death affects the patients' bereaved spouses, who risk developing prolonged grief. In Denmark palliative care is most often offered to cancer patients.

AIM

We aimed to investigate the experience of spouses of f-ILD patients during the final stages of illness and up to the first year after the patient's death to investigate if palliative care could ease the transition and prevent PGD.

METHODS

Our study had a qualitative design triangulating in-depth interviews, field notes, participant diaries and the prolonged grief questionnaire PG-13. We included 20 spouses and applied thematic analysis. Initial coding was performed deductively according to the chronological stages of before, during and after the death of the patient. We subsequently coded inductively within the stages.

RESULTS

During the final days the spouses experienced emotional ambivalence shifting between hope, acceptance and despair. Factors affecting the spouses during the final hours were the timing, location, and process of death. After the patient's death the spouses experienced feelings of grief and optimism as they moved toward a new life on their own.

CONCLUSIONS

Some of the factors affecting the spouses and potentially causing prolonged grief might be alleviated by offering palliative/supportive care and advance care planning to f-ILD patients and their family.

The Lived Experience of Korean Female Military Nursing Officers During the Vietnam War

Introduction: Between 1964 and 1973, more than 550 Korean female nursing officers were deployed to the Vietnam War as part of the Korean military. Their achievements were overshadowed by the male combat troops. The purpose of this study was to explore the essence of their lived experiences. Method: Using the hermeneutic phenomenological approach, the data were collected through in-depth interviews with 14 Korean female nursing officers who were deployed to the Vietnam War. Results: Seven essential themes were derived: Enduring confusion, Being devoted to duty, Establishing deep comradeship, Realizing the dark side of war, Being discriminated against as female, Achieving and being rewarded, and Growing as leaders. Conclusion: This study acquired valuable data on nursing history and useful information on the psychological, physical, and environmental difficulties that could be faced by female nurses working in conflicts, wars, and disaster situations.

Art and Mental Health Recovery: Evaluating the Impact of a Community-Based Participatory Arts Program Through Artist Voices

This study sought to evaluate the impact of participation in a 6-month community-based participatory arts program on mental health recovery. Using a case study methodology, a total of nine recent graduates from one of five separate groups held during the study period (2012-2015) were interviewed. All but one of the nine participants reported positive personal, emotional, physical and/or mental health changes as a result of her or his participation in the program. Voices of all participants are explored. Analysis of the interviews revealed four key themes: safe space to create, change in identity, biggest impact, and program-related challenges. This study supports community-based arts programming as a positive experience for people living with mental illness. Employing staff and volunteers with lived experience of mental health problems enhanced the overall participant experience.

Job Satisfaction Among Japanese Home-Visit Care Workers

The present qualitative study aims to shed light on the job satisfaction of home-visit care workers in Japan. A total of 19 participants were recruited from two rural, three suburban, and one urban area in and around Nagoya city. The qualitative data were collected through individual or group interviews from May to August of 2017. The interviews were conducted using an open-ended questionnaire concerning job satisfaction. Qualitative content analysis was used to systematically identify ideas and patterns emerging from the interview data. Three main themes emerged from the analysis: client–worker conflict, public opinion about the profession, and changing but rewarding work. Home-visit care workers enjoy working in an environment where communication is highly valued, and appreciate the diversity of their clients’ personalities.

The Daily Mile: What factors are associated with its implementation success?

BACKGROUND

Despite the known benefits of a physically active lifestyle, there are few examples of interventions that have been successfully implemented at a population level over a long period of time. One such example is The Daily Mile, a school based physical activity initiative, where a teacher takes their class out daily during class time for a short bout of ambulatory activity. At one school, this activity appears has been sustained over a long period (6 years), has the whole school participating and is now incorporated into its daily routine. The aim of this paper was to understand how The Daily Mile was implemented in primary schools and to assess factors associated with its successful implementation.

METHODS

Semi-structured interviews with school staff who had a significant role in implementing The Daily Mile were conducted at four primary schools in central Scotland. Interviews were digitally recorded and transcribed verbatim. Data were analysed using thematic analysis and descriptive analysis and interpretation of data undertaken. Details regarding the school grounds and facilities were also noted during the interviews.

RESULTS

Having simple core intervention components, flexible delivery that supports teacher autonomy and being adaptable to suit the specific primary school context appear to be key aspects of The Daily Mile that are related to its implementation success. Other factors relating to how The Daily Mile was developed, trialled and rolled out might also have contributed towards its successful implementation.

CONCLUSION

The Daily Mile appears to have several factors which may relate to its implementation success. These are important considerations for others looking to implement The Daily Mile effectively in their primary school or in other contexts.

Rural Postpartum Women With Substance Use Disorders

The incidence of perinatal opioid use and neonatal withdrawal continues to rise rapidly in the face of the growing opioid addiction epidemic in the United States, with rural areas more severely affected. Despite decades of research and development of practice guidelines, maternal and neonatal outcomes have not improved substantially. This focused ethnography sought to understand the experience of accessing care necessary for substance use disorder recovery, pregnancy, and parenting. Personal accounts of 13 rural women, supplemented by participant observation and media artifacts, uncovered three domains with underlying themes: challenges of getting treatment and care (service availability, distance/geographic location, transportation, provider collaboration/coordination, physical and emotional safety), opportunities to bond (proximity, information), and importance of relationships (respect, empathy, familiarity, inclusion, interactions with care providers). Findings highlight the need for providers and policy makers to reduce barriers to treatment and care related to logistics, stigma, judgment, and lack of understanding of perinatal addiction.

Factors Affecting Sexual History Taking in a Health Center Serving Homeless Persons

Low rates of documentation of sexual histories have been reported and research on sexual history taking (SHT) has focused on the content of, barriers to collecting, and interventions to improve documentation of sexual histories. Absent from this literature is an understanding of the contextual factors affecting SHT. To address this gap, a focused ethnography of one health center was conducted. Data were collected through observations of health care encounters and interviews with health care providers (HCPs). No SHT was observed and this was likely influenced by patients' characteristics, communication between patients and HCPs, the prioritization of patients' basic needs, and time constraints imposed upon encounters. Given that the health center studied serves patients experiencing homelessness, behavioral health concerns, and opioid use disorder, findings illuminate areas for future inquiry into a patient population affected by social as well as physiologic determinants of health and potentially at high risk for adverse sexual health outcomes.

"It's Not Much of a Life": The Benefits and Ethics of Using Life History Methods With People Who Inject Drugs in Qualitative Harm Reduction Research

A life history approach enables study of how risk or health protection is shaped by critical transitions and turning points in a life trajectory and in the context of social environment and time. We employed visual and narrative life history methods with people who inject drugs to explore how hepatitis C protection was enabled and maintained over the life course. We overview our methodological approach, with a focus on the ethics in practice of using life history timelines and life-grids with 37 participants. The life-grid evoked mixed emotions for participants: pleasure in receiving a personalized visual history and pain elicited by its contents. A minority managed this pain with additional heroin use. The methodological benefits of using life history methods and visual aids have been extensively reported. Crucial to consider are the ethical implications of this process, particularly for people who lack socially ascribed markers of a "successful life."

Health Care Experiences of Korean Women Divers (Jeju Haenyeos)

Jeju haenyeos who enter the sea without equipment to collect seafood while holding their breath have a unique culture; however, studies of their health are limited. This study, using an ethnographic approach, explores how Jeju haenyeos have managed and maintained their health. Snowball sampling yielded 15 participants between July and October 2016. We collected data through participant observation and in-depth interviews and conducted Spradley's research sequence. The main theme of the health-management approach of these women was "a life of listening to the body and mind, controlling greed, and adjusting work for safe diving." However, Jeju haenyeos used preventive drugs and excessive doses of other drugs and lacked an understanding of the ways diverse drugs potentially interact. These findings suggest that community nurses should be cautious and should attempt to educate these patients.

Facilitators and Barriers to Being Physically Active in a Rural Hawai'i Community: A Photovoice Perspective

A large body of existing literature suggests associations between perceptions of the environment and physical activity status, but very few studies have examined perceptions among Native Hawaiian and Pacific Islander (NHPI) communities. The purpose of this study was to examine perceptions of the active living environment in Hawai‘i in rural communities with a high proportion of NHPI. A total of thirteen adults were purposefully selected to participate in the study, and the Photovoice method was used to capture their perceptions. Three sessions were used to describe the purpose of the study, select and describe photographs, and identify emerging themes. A total of nine overarching themes were identified by participants and placed into three categories. Participants identified facilitators to being physically active, but also identified several barriers in their community such as the lack of available physical and built amenities, social norms, and safety. Participants proposed four action items to improve their active living environment: promote programs that are organized by community members, contact the local university to provide access to physical activity equipment, contact Honolulu City & County officials to voice concerns regarding barriers that prevent physical activity in the community, and working with employers in the community to create policies that promote physical activity at the workplace.

Doing implementation research on health governance: a frontline researcher's reflexive account of field-level challenges and their management

Background

Implementation Research (IR) in and around health systems comes with unique challenges for researchers including implementation, multi-layer governance, and ethical issues. Partnerships between researchers, implementers, policy makers and community members are central to IR and come with additional challenges. In this paper, we elaborate on the challenges faced by frontline field researchers, drawing from experience with an IR study on Village Health Sanitation and Nutrition Committees (VHSNCs).

Methods

The IR on VHSNC took place in one state/province in India over an 18-month research period. The IR study had twin components; intervention and in-depth research. The intervention sought to strengthen the VHSNC functioning, and concurrently the research arm sought to understand the contextual factors, pathways and mechanism affecting VHSNC functions. Frontline researchers were employed for data collection and a research assistant was living in the study sites. The frontline research assistant experienced a range of challenges, while collecting data from the study sites, which were documented as field memos and analysed using inductive content analysis approach.

Results

Due to the relational nature of IR, the challenges coalesced around two sets of relationships (a) between the community and frontline researchers and (b) between implementers and frontline researchers. In the community, the frontline researcher was viewed as the supervisor of the intervention and was perceived by the community to have power to bring about beneficial changes with public services and facilities. Implementers expected help from the frontline researcher in problem-solving in VHSNCs, and feedback on community mobilization to improve their approaches. A concerted effort was undertaken by the whole research team to clarify and dispel concerns among the community and implementers through careful and constant communication. The strategies employed were both managerial, relational and reflexive in nature.

Conclusion

Frontline researchers through their experiences shape the research process and its outcome and they play a central role in the research. It demonstrates that frontline researcher resilience is very crucial when conducting health policy and systems research.