Participatory research-A modernizing science for primary health care

Participatory Approaches in the Context of Research Into Workplace Health Promotion to Improve Physical Activity Levels and Reduce Sedentary Behavior Among Office-Based Workers: Scoping Review

BACKGROUND

Participatory research (PR) involves engaging in cocreation with end users and relevant stakeholders throughout the research process, aiming to distribute power equitably between the end users and research team. Engagement and adherence in previous workplace health promotion (WHP) studies have been shown to be lacking. By implementing a PR approach, the insights of end users and stakeholders are sought in the co-design of feasible and acceptable intervention strategies, thereby increasing the relevance of the research.

OBJECTIVE

This scoping review aims to explore, identify, and map PR techniques and their impact when used in office-based WHP interventions designed to improve physical activity (PA) or reduce sedentary behavior (SB).

METHODS

The reporting of this scoping review followed the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). A systematic literature search of 5 electronic databases-Web of Science, PubMed, Scopus, Google Scholar, and OpenGrey-was conducted, searching from January 1, 1995, to February 8, 2023. In total, 2 independent reviewers first screened the retrieved articles by title and abstract, and then assessed the full texts based on the inclusion and exclusion criteria. The search strategy and eligibility criteria were developed and guided by an a priori population (office-based working adults), intervention (a PA WHP intervention that took a PR approach), comparison (no comparison required), and outcome (PA or SB) framework. Data were charted and discussed via a narrative synthesis, and a thematic analysis was conducted. The included studies were evaluated regarding the degree of end user engagement throughout the research process and power shared by the researchers, using Arnstein's ladder of citizen participation.

RESULTS

The search retrieved 376 records, of which 8 (2.1%) met the inclusion criteria. Four key strategies were identified: (1) end user focus groups, (2) management involvement, (3) researcher facilitators, and (4) workplace champions. The degree of engagement and power shared was relatively low, with 25% (2/8) of the studies determined to be nonparticipation studies, 25% (2/8) determined to be tokenistic, and 50% (4/8) determined to provide citizen power.

CONCLUSIONS

This review provides a foundation of evidence on the current practices when taking a PR approach, highlighting that previous office-based PA WHP studies have been largely tokenistic or nonparticipative, and identified that the end user is only engaged with in the conception and implementation of the WHP studies. However, a positive improvement in PA and reduction in SB were observed in the included studies, which were largely attributed to implementing a PR approach and including the end user in the design of the WHP intervention. Future studies should aim to collaborate with workplaces, building capacity and empowering the workforce by providing citizen control and letting the end users "own" the research for a sustainable WHP intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2021-054402.

Fuzzy cognitive mapping in participatory research and decision making: a practice review

BACKGROUND

Fuzzy cognitive mapping (FCM) is a graphic technique to describe causal understanding in a wide range of applications. This practice review summarises the experience of a group of participatory research specialists and trainees who used FCM to include stakeholder views in addressing health challenges. From a meeting of the research group, this practice review reports 25 experiences with FCM in nine countries between 2016 and 2023.

RESULTS

The methods, challenges and adjustments focus on participatory research practice. FCM portrayed multiple sources of knowledge: stakeholder knowledge, systematic reviews of literature, and survey data. Methodological advances included techniques to contrast and combine maps from different sources using Bayesian procedures, protocols to enhance the quality of data collection, and tools to facilitate analysis. Summary graphs communicating FCM findings sacrificed detail but facilitated stakeholder discussion of the most important relationships. We used maps not as predictive models but to surface and share perspectives of how change could happen and to inform dialogue. Analysis included simple manual techniques and sophisticated computer-based solutions. A wide range of experience in initiating, drawing, analysing, and communicating the maps illustrates FCM flexibility for different contexts and skill bases.

CONCLUSIONS

A strong core procedure can contribute to more robust applications of the technique while adapting FCM for different research settings. Decision-making often involves choices between plausible interventions in a context of uncertainty and multiple possible answers to the same question. FCM offers systematic and traceable ways to document, contrast and sometimes to combine perspectives, incorporating stakeholder experience and causal models to inform decision-making. Different depths of FCM analysis open opportunities for applying the technique in skill-limited settings.

'Atawhai': a primary care provider-led response to family violence in Aotearoa New Zealand

BACKGROUND

As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence.

METHODS

Underpinned by indigenous Māori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti kōrero wānanga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wānanga and observation methods. Methods used to capture change will be reported separately.

FINDINGS

Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings.

CONCLUSIONS

Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs.

Active involvement in scientific research of persons living with dementia and long-term care users: a systematic review of existing methods with a specific focus on good practices, facilitators and barriers of involvement

BACKGROUND

Active involvement of persons living with dementia (PLWD) and long-term care (LTC) users in research is essential but less developed compared to other patient groups. However, their involvement in research is not only important but also feasible. This study aims to provide an overview of methods, facilitators, and barriers for involving PLWD and LTC users in scientific research.

METHODS

A systematic literature search across 12 databases in December 2020 identified studies involving PLWD, LTC users, or their carers beyond research subjects and describing methods or models for involvement. Qualitative descriptions of involvement methods underwent a risk of bias assessment using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist 2018. A data collection sheet in Microsoft Excel and thematic analysis were used to synthesize the results.

RESULTS

The eighteen included studies delineated five core involvement methods spanning all research phases: advisory groups, formal and informal research team meetings, action groups, workshops, and co-conducting interviews. Additionally, two co-research models with PLWD and carers were found, while only two studies detailed LTC user involvement methods. Four distinct involvement roles were identified: consulting and advisory roles, co-analysts, co-researchers, and partners. The review also addressed barriers, facilitators, and good practices in the preparation, execution, and translation phases of research, emphasizing the importance of diversity, bias reduction, and resource allocation. Trust-building, clear roles, ongoing training, and inclusive support were highlighted.

CONCLUSIONS

Planning enough time for active involvement is important to ensure that researchers have time to build a trusting relationship and meet personal needs and preferences of PLWD, LTC users and carers. Researchers are advised not to presume the meaning of burden and to avoid a deficit perspective. A flexible or emergent design could aid involved persons' ownership of the research process.

TRIAL REGISTRATION

Prospero 2021: CRD42021253736.

HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.

Symptom Science in Kidney Disease

Physical and emotional symptoms are highly prevalent among patients with kidney disease and are directly linked to impaired health-related quality of life. Symptom science is a field of research aimed at advancing knowledge of the holistic mechanisms driving symptoms, how best to assess symptoms accurately, and developing novel and patient-centered approaches to symptom management. Patients with kidney disease have identified symptom science as a top research priority, and opportunities abound for ongoing patient engagement in symptom-related research efforts and clinical care. This review describes the burden of symptoms experienced by patients with kidney disease, explores the spectrum of patient engagement in symptom care and research, and discusses approaches for symptom assessment and management, taking into consideration the multitude of factors that may contribute to symptoms.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

Competency-Based Cultural Safety Training in Medical Education at La Sabana University, Colombia: A Roadmap of Curricular Modernization

Issue: Cultural safety enhances equitable communication between health care providers and cultural groups. Most documented cultural safety training initiatives focus on Indigenous populations from high-income countries, and nursing students, with little research activity reported from low- and middle-income countries. Several cultural safety training initiatives have been described, but a modern competency-based cultural safety curriculum is needed. Evidence: In this article, we present the Competency-Based Education and Entrustable Professional Activities frameworks of the Faculty of Medicine at La Sabana University in Colombia, and illustrate how this informed modernization of medical education. We describe our co-designed cultural safety training learning objectives and summarize how we explored its impact on medical education through mixed-methods research. Finally, we propose five cultural safety intended learning outcomes adapted to the updated curriculum, which is based on the Competency-Based Education model. Implications: This article presents five cultural safety intended learning outcomes for undergraduate medical education. These learning outcomes are based on Competency-Based Education and the Entrustable Professional Activities framework and can be used by faculties of medicine interested in including the cultural safety approach in their curriculum.

How does participatory research work: protocol for a realist synthesis

INTRODUCTION

Participatory research science deals with partnerships underlying research, governance and ownership of research products. It is concerned with relationships behind research objectives and methods. Participatory research has gained significant traction in design of health interventions, contextualising these to local settings and stakeholder groups. Despite a massive increase in participatory research exercises, the field remains undertheorised, and the mechanisms for improving health outcomes remain unclear. This realist review seeks to understand how and under what circumstances participatory research impacts health and social outcomes.

METHODS AND ANALYSIS

The review will follow four steps: (1) searching for and selecting evidence, (2) assessing the quality of evidence, (3) extracting and categorising data and (4) synthesising the data in the form of context-mechanism-outcomes configurations. The review will follow the Realist And Meta Narrative Evidence Syntheses: Evolving Standards (RAMESES) II guidelines for reporting realist evaluations. We categorise and synthesise data in four steps: (1) identifying outcomes, (2) identifying contextual components of outcomes, (3) theoretical redescription (abduction) and (4) identifying mechanisms. A retroductive analysis will identify mechanisms by moving between empirical data and theories, using inductive and deductive reasoning to explain the outcomes-context matches. The output will generate middle-range theories on how participatory research works, for whom and under what circumstances.

ETHICS AND DISSEMINATION

This study is a review of a published literature. It does not involve human participants. We will convene a workshop to share and discuss the preliminary results with partners and key stakeholders involved in participatory health research. We will publish the review results in peer-reviewed journals and academic conferences.

What facilitates or prevents academic fraud in a Colombian faculty of medicine-Protocol of a study using fuzzy cognitive mapping

INTRODUCTION

Academic fraud is any behavior that gives a student an undeserved advantage over another student. Few studies have explored the causes of and possible solutions to academic fraud in Latin America. We aim to map the knowledge of stakeholders in a Colombian faculty of medicine about the factors that facilitate and prevent academic fraud.

METHODS

Fuzzy cognitive mapping. We will use the approach proposed by Andersson and Silver to generate fuzzy cognitive maps representing stakeholder knowledge. This process consists of ten steps: (1) definition of the research question; (2) identification of participants; (3) generation of ideas; (4) rationalization of ideas; (5) organization and connection of ideas; (6) weighing; (7) pattern grouping; (8) list of links and digitization; (9) combination of maps and network analysis; and (10) deliberative dialogue. To draw the maps, we will invite medical students, interns, resident physicians, master's students, and professors in the faculty of medicine. Four medical students will receive training to facilitate the sessions. Participants will identify the factors contributing to academic fraud and their causal relationships. We will use a combination of network analysis and graph theory to identify the chains of factors with greatest influence on academic fraud.

CONCLUSION

The maps will serve to discuss strategies to reduce academic fraud in the Faculty of Medicine and to identify factors that could be addressed in other contexts with similar problems. This research will allow the students who facilitate mapping sessions to learn about research techniques, fuzzy cognitive mapping and academic fraud. Study registration: Registered in OSF Registries on August 2nd, 2022. Registration number: osf.io/v4amz.

The Possibility and Promise of Action Research in Pediatrics: A Scoping Review

Action research (AR) is an umbrella term encompassing a range of related research approaches and frameworks such as participatory AR, participatory research, community-based participatory research, and community-engaged research. In contrast to conventional, investigator-led research that is conducted on or about participants, AR is conducted with those who have a "stake" in the research topic. Despite growing acceptance as an established research approach, AR is noticeably limited within pediatric health care literature. Following a structured process, we conducted a scoping review to explore AR in pediatrics within the last 10 years. Twenty-eight articles met eligibility criteria. Study themes included eliciting stakeholder perspectives, improving stakeholder experiences, and developing/evaluating tools. Future AR in pediatrics should include the measurement of specific health outcomes and greater detail of the actionable steps that resulted from the research process. Action research has potential application to improve the quality and stakeholder relevance of pediatric clinical, educational, and community research.

Energy efficient ventilation and indoor air quality in the context of COVID-19 - A systematic review

New COVID-19 ventilation guidelines have resulted in higher energy consumption to maintain indoor air quality (IAQ), and energy efficiency has become a secondary concern. Despite the significance of the studies conducted on COVID-19 ventilation requirements, a comprehensive investigation of the associated energy challenges has not been discussed. This study aims to present a critical systematic review of the Coronavirus viral spreading risk mitigation through ventilation systems (VS) and its relation to energy use. COVID-19 heating, ventilation and air conditioning (HVAC)-related countermeasures proposed by industry professionals have been reviewed and their influence on operating VS and energy consumption have also been discussed. A critical review analysis was then conducted on publications from 2020 to 2022. Four research questions (RQs) have been selected for this review concerning i) maturity of the existing literature, ii) building types and occupancy profile, iii) ventilation types and effective control strategies and iv) challenges and related causes. The results reveal that employing HVAC auxiliary equipment is mostly effective and increased fresh air supply is the most significant challenge associated with increased energy consumption due to maintaining IAQ. Future studies should focus on novel approaches toward solving the apparently conflicting objectives of minimizing energy consumption and maximizing IAQ. Also, effective ventilation control strategies should be assessed in various buildings with different occupancy densities. The implications of this study can be useful for future development of this topic not only to enhance the energy efficiency of the VS but also to enable more resiliency and health in buildings.

Community-engaged research in vascular surgery: An approach to decrease amputation disparities and effect population-level change

Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including them throughout the research process. Such engagement increases the relevance and meaning of research, improves the translation of research findings into sustainable health policy and practice, and ultimately enhances mutual trust among academic, clinical, and community partners for ongoing research partnership. There are a number of key principles that must be considered in the planning, design, and implementation of CEnR. These principles are focused on inclusive representation and participation, community empowerment, building community capacity, and protecting community self-determination. Although vascular surgeons may not be equipped to address these issues from the ground up by themselves, they should work with a team who can help them incorporate these elements into their CEnR project designs and proposals. This may be best accomplished by collaborating with researchers and community-based organizations who already have this expertise and have established social capital within the community. This article describes the theory and principles of CEnR, its relevance to vascular surgeons, researchers, and patients, and how using CEnR principles in vascular surgery practice, research, and outreach can benefit our patient population, with a specific focus on reducing disparities related to amputation.

Shifting paradigm from biomedical to decolonised methods in Inuit public health research in Canada: a scoping review

Background

The National Inuit Strategy on Research focuses on advancing Inuit governance in research, increasing ownership over data and building capacity. Responding to this call for Inuit self-determination in research, academic researchers should consider cultural safety in research and ways to promote Inuit-led methods.

Methods

This scoping review collated academic literature on public health research in Inuit communities in Canada between 2010 and 2022. A critical assessment of methods used in public health research in Inuit communities examined cultural safety and the use of Inuit-attuned methods. Descriptive and analytical data were summarised in tables and figures. Knowledge user engagement in the research process was analysed with thematic analysis.

Results

356 articles met the inclusion criteria. Much of the published research was in nutrition and mental health, and few initiatives reported translation into promotion programmes. Almost all published research was disease or deficit focused and based on a biomedical paradigm, especially in toxicology, maternal health and chronic diseases. Recent years saw an increased number of participatory studies using a decolonial lens and focusing on resilience. While some qualitative research referred to Inuit methodologies and engaged communities in the research process, most quantitative research was not culturally safe. Overall, community engagement remained in early stages of co-designing research protocols and interventions. Discussion on governance and data ownership was limited. Recent years saw emerging discussions on these issues. Knowledge user capacity-building was limited to brief training on conventional data collection methods.

Conclusions

The last decade of published public health research has not responded to the National Inuit Strategy on Research. Participatory research is gaining ground, but has not reached its full potential. A shift from biomedical to decolonised methods is slowly taking place, and public health researchers who have not yet embraced this paradigm shift should do so.

Weight of Evidence: Participatory Methods and Bayesian Updating to Contextualize Evidence Synthesis in Stakeholders' Knowledge

Mixed methods research is well-suited to grapple with questions of what counts as valid knowledge across different contexts and perspectives. This article introduces Weight of Evidence as a transformative procedure for stakeholders to interpret, expand on and prioritize evidence from evidence syntheses, with a focus on engaging populations historically excluded from planning and decision making. This article presents the procedure's five steps using pilot data on perinatal care of immigrant women in Canada, engaging family physicians and birth companions. Fuzzy cognitive mapping offers an accessible and systematic way to generate priors to update published literature with stakeholder priorities. Weight of Evidence is a transparent procedure to broaden what counts as expertise, contributing to a more comprehensive, context-specific, and actionable understanding.

Medical Trainees Comfort and Confidence in Providing Care to Arab and Muslim Patients at a Large Academic Medical Center

PHENOMENON

There are currently 3.5 million Americans of Arab descent and 3.45 million Muslims living in the United States. These rapidly growing populations face significant health disparities, which is likely in part due to the lack of culturally competent physicians trained to treat these populations. While the Institute of Medicine calls for cross-cultural training for all providers, it is not clear if this need is being met. The purpose of this study is to examine medical trainees' current level of cultural training and whether this corresponds to confidence in caring for Arab and Muslim patients.

APPROACH

The authors created an anonymous survey that was distributed via email to medical students and residents at Michigan Medicine between January and March 2020. Questions included trainees' comfort and confidence level in caring for Arab and Muslim patients, as well education received on this topic.

FINDINGS

Results showed that 41% of respondents were confident in their ability to take a history from an Arab patient immigrated to the U.S. Additionally, 55% of non-Muslim participants reported that they felt comfortable in caring for fasting patients, while only 24% felt confident in their ability to answer patient questions about fasting. Approximately half of respondents felt confident in their ability to examine an Arabic-speaking woman (47%) or woman wearing a hijab (49%). The majority of respondents had not received any training or education in the care of Arab patients (64%) or fasting patients (81%).

INSIGHT

Medical trainees at one large academic medical center in the state with the second largest Arab-American population, and one of the largest populations of Muslim-Americans lack comfort and confidence in providing culturally competent care for Arab and Muslim patients. Education of trainees about Arab and Muslim health should be implemented into the curriculum to optimize care delivered to this patient population.

First Demonstration of Functional Task Performance Using a Sonomyographic Prosthesis: A Case Study

Ultrasound-based sensing of muscle deformation, known as sonomyography, has shown promise for accurately classifying the intended hand grasps of individuals with upper limb loss in offline settings. Building upon this previous work, we present the first demonstration of real-time prosthetic hand control using sonomyography to perform functional tasks. An individual with congenital bilateral limb absence was fitted with sockets containing a low-profile ultrasound transducer placed over forearm muscle tissue in the residual limbs. A classifier was trained using linear discriminant analysis to recognize ultrasound images of muscle contractions for three discrete hand configurations (rest, tripod grasp, index finger point) under a variety of arm positions designed to cover the reachable workspace. A prosthetic hand mounted to the socket was then controlled using this classifier. Using this real-time sonomyographic control, the participant was able to complete three functional tasks that required selecting different hand grasps in order to grasp and move one-inch wooden blocks over a broad range of arm positions. Additionally, these tests were successfully repeated without retraining the classifier across 3 hours of prosthesis use and following simulated donning and doffing of the socket. This study supports the feasibility of using sonomyography to control upper limb prostheses in real-world applications.

Challenges and Feasibility of Co-Design Methods for Improving Parent Information in Maternity Care

This study explored the feasibility of using experience-based co-design methods (EBCD), based on participatory action principles, to improve service delivery regarding parent information needs within a metropolitan postnatal maternity unit. Data were collected from January 2018 to March 2019 from parents and staff using surveys, video interviews, a focus group and ward observations of episodes where parents were provided information. Participants included postnatal mothers who had recently given birth, their partners and hospital staff. Survey results (n = 31) were positive regarding content and satisfaction with information delivery. Data from the staff focus group (seven participants) and in-depth video interviews with mothers (n = 4) identified common themes, including challenges to information delivery due to time pressures, the value of breastfeeding advice and environmental influences. Overall, parents were satisfied with the information delivered; however, inconsistencies were present, with time pressures and other environmental factors reported as influencing the process. Staff and parents both identified the amount of content being delivered in such a short time frame as a major challenge and tailoring information was difficult due to individual experiences and circumstances. Additional resources or alternative methods are suggested for conducting future studies to capture patient experience within a similar busy hospital setting.

'Down to the person, the individual patient themselves': A qualitative study of treatment decision-making for shoulder pain

Introduction

Many inconsistencies have been identified in the translation of evidence‐based treatment recommendations for musculoskeletal shoulder pain into healthcare services, with little known about factors influencing decision‐making. The objective of this study was to explore the views and experiences of healthcare providers (HCPs) and people living with shoulder pain on treatment decision‐making.

Methods

Adopting a qualitative design, purposeful sampling was employed to recruit 13 individuals with nonspecific musculoskeletal shoulder pain and 30 HCPs. Data were collected through 1:1 semi‐structured interviews and analysed using an approach informed by Constructivist Grounded Theory. To facilitate analysis, two patient and public involvement (PPI) meetings were conducted.

Results

Most participants (69%) had shoulder pain of ≥1‐year duration. Biomechanical beliefs about shoulder pain predominated and were heavily influential in decision‐making for both patients and HCPs. Despite a consensus that therapeutic alliance facilitated decision‐making, the extent of collaboration between HCPs and patients in treatment decision‐making was rather limited. In addition to condition‐specific factors, Individual patient characteristics and resources also influenced treatment decisions.

Conclusion

Findings revealed the complexity of the decision‐making process for both patients and HCPs, exposing substantial gaps between the reported views and experiences of participants and the principles of client‐centred and evidence‐based practice. There is a pressing need to enhance the translation of evidence‐based knowledge into practice in this clinical area.

Patient or Public Contribution

In line with a consultative approach to collaborative data analysis, a subgroup of participants attended two PPI meetings to provide commentary and feedback on preliminary findings.

Impact-Oriented Dialogue for Culturally Safe Adolescent Sexual and Reproductive Health in Bauchi State, Nigeria: Protocol for a Codesigned Pragmatic Cluster Randomized Controlled Trial

BACKGROUND

Adolescents (10-19 years) are a big segment of the Nigerian population, and they face serious risks to their health and well-being. Maternal mortality is very high in Nigeria, and rates of pregnancy and maternal deaths are high among female adolescents. Rates of HIV infection are rising among adolescents, gender violence and sexual abuse are common, and knowledge about sexual and reproductive health risks is low. Adolescent sexual and reproductive health (ASRH) indicators are worse in the north of the country.

OBJECTIVE

In Bauchi State, northern Nigeria, the project will document the nature and extent of ASRH outcomes and risks, discuss the findings and codesign solutions with local stakeholders, and measure the short-term impact of the discussions and proposed solutions.

METHODS

The participatory research project is a sequential mixed-methods codesign of a pragmatic cluster randomized controlled trial. Focus groups of local stakeholders (female and male adolescents, parents, traditional and religious leaders, service providers, and planners) will identify local priority ASRH concerns. The same stakeholder groups will map their knowledge of factors causing these concerns using the fuzzy cognitive mapping (FCM) technique. Findings from the maps and a scoping review will inform the contextualization of survey instruments to collect information about ASRH from female and male adolescents and parents in households and from local service providers. The survey will take place in 60 Bauchi communities. Adolescents will cocreate materials to share the findings from the maps and survey. In 30 communities, randomly allocated, the project will engage adolescents and other stakeholders in households, communities, and services to discuss the evidence and to design and implement culturally acceptable actions to improve ASRH. A follow-up survey in communities with and without the intervention will measure the short-term impact of these discussions and actions. We will also evaluate the intervention process and use narrative techniques to assess its impact qualitatively.

RESULTS

Focus groups to explore ASRH concerns of stakeholders began in October 2021. Baseline data collection in the household survey is expected to take place in mid-2022. The study was approved by the Bauchi State Health Research Ethics Committee, approval number NREC/03/11/19B/2021/03 (March 1, 2021), and by the Faculty of Medicine and Health Sciences Institutional Review Board McGill University (September 13, 2021).

CONCLUSIONS

Evidence about factors related to ASRH outcomes in Nigeria and implementation and testing of a dialogic intervention to improve these outcomes will fill a gap in the literature. The project will document and test the effectiveness of a participatory approach to ASRH intervention research.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN18295275; https://www.isrctn.com/ISRCTN18295275.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/36060.

Participatory health research under COVID-19 restrictions in Bauchi State, Nigeria: Feasibility of cellular teleconferencing for virtual discussions with community groups in a low-resource setting

INTRODUCTION

During the COVID-19 pandemic, researchers have used Internet-based applications to conduct virtual group meetings, but this is not feasible in low-resource settings. In a community health research project in Bauchi State, Nigeria, COVID-19 restrictions precluded planned face-to-face meetings with community groups. We tested the feasibility of using cellular teleconferencing for these meetings.

METHODS

In an initial exercise, we used cellular teleconferencing to conduct six male and six female community focus group discussions. Informed by this experience, we conducted cellular teleconferences with 10 male and 10 female groups of community leaders, in different communities, to discuss progress with previously formulated action plans. Ahead of each teleconference call, a call coordinator contacted individual participants to seek consent and confirm availability. The coordinator connected the facilitator, the reporter, and the participants on each conference call, and audio-recorded the call. Each call lasted less than 1 h. Field notes and debriefing meetings with field teams supported the assessment of feasibility of the teleconference meetings.

RESULTS

Cellular teleconferencing was feasible and inexpensive. Using multiple handsets at the base allowed more participants in a call. Guidelines for facilitators and participants developed after the initial meetings were helpful, as were reminder calls ahead of the meeting. Connecting women participants was challenging. Facilitators needed extra practice to support group interactions without eye contact and body language signals.

CONCLUSIONS

With careful preparation and training, cellular teleconferencing can be a feasible and inexpensive method of conducting group discussions in a low-resource setting.

Bridging Western and Indigenous knowledge through intercultural dialogue: lessons from participatory research in Mexico

Indigenous communities in Latin America and elsewhere have complex bodies of knowledge, but Western health services generally approach them as vulnerable people in need of external solutions. Intercultural dialogue recognises the validity and value of Indigenous standpoints, and participatory research promotes reciprocal respect for stakeholder input in knowledge creation.As part of their decades-long community-based work in Mexico's Guerrero State, researchers at the Centro de Investigación de Enfermedades Tropicales responded to the request from Indigenous communities to help them address poor maternal health. We present the experience from this participatory research in which both parties contributed to finding solutions for a shared concern. The aim was to open an intercultural dialogue by respecting Indigenous skills and customs, recognising the needs of health service stakeholders for scientific evidence.Three steps summarise the opening of intercultural dialogue. Trust building and partnership based on mutual respect and principles of cultural safety. This focused on understanding traditional midwifery and the cultural conflicts in healthcare for Indigenous women. A pilot randomised controlled trial was an opportunity to listen and to adjust the lexicon identifying and testing culturally coherent responses for maternal health led by traditional midwives. Codesign, evaluation and discussion happened during a full cluster randomised trial to identify benefits of supporting traditional midwifery on maternal outcomes. A narrative mid-term evaluation and cognitive mapping of traditional knowledge offered additional evidence to discuss with other stakeholders the benefits of intercultural dialogue. These steps are not mechanistic or invariable. Other contexts might require additional steps. In Guerrero, intercultural dialogue included recovering traditional midwifery and producing high-level epidemiological evidence of the value of traditional midwives, allowing service providers to draw on the strengths of different cultures.

Mental-physical multimorbidity treatment adherence challenges in Brazilian primary care: A qualitative study with patients and their healthcare providers

Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization.

Causes of short birth interval (kunika) in Bauchi State, Nigeria: systematizing local knowledge with fuzzy cognitive mapping

BACKGROUND

Short birth intervals, defined by the World Health Organization as less than 33 months, may damage the health and wellbeing of children, mothers, and their families. People in northern Nigeria recognise many adverse effects of short birth interval (kunika in the Hausa language) but it remains common. We used fuzzy cognitive mapping to systematize local knowledge of causes of kunika to inform the co-design of culturally safe strategies to address it.

METHODS

Male and female groups in twelve communities built 48 maps of causes and protective factors for kunika, and government officers from the Local Government Area (LGA) and State made four maps. Each map showed causes of kunika or no-kunika, with arrows showing relationships with the outcome and between causes. Participants assigned weights for the perceived strength of relationships between 5 (strongest) and 1 (weakest). We combined maps for each group: men, women, and government officers. Fuzzy transitive closure calculated the maximum influence of each factor on the outcome, taking account of all relationships in the map. To condense the maps, we grouped individual factors into broader categories and calculated the cumulative net influence of each category. We made further summarised maps and presented these to the community mapping groups to review.

RESULTS

The community maps identified frequent sex, not using modern or traditional contraception, and family dynamics (such as competition between wives) as the most influential causes of kunika. Women identified forced sex and men highlighted lack of awareness about contraception and fear of side effects as important causes of kunika. Lack of male involvement featured in women's maps of causes and in the maps from LGA and State levels. Maps of protective factors largely mirrored those of the causes. Community groups readily appreciated and approved the summary maps resulting from the analysis.

CONCLUSIONS

The maps showed how kunika results from a complex network of interacting factors, with culture-specific dynamics. Simply promoting contraception alone is unlikely to be enough to reduce kunika. Outputs from transitive closure analysis can be made accessible to ordinary stakeholders, allowing their meaningful participation in interpretation and use of the findings. For people in Bauchi State, northern Nigeria, kunika describes a short interval between successive births, understood as becoming pregnant again before the previous child is weaned. They recognise it is bad for children, mothers and households. We worked with 12 communities in Bauchi to map their knowledge of the causes and protective factors for kunika. Separate groups of men and women built 48 maps, and government officers at local and state level built four maps. Each group drew two maps showing causes of kunika or of no-kunika with arrows showing the links between causes and the outcome. Participants marked the strength of each link with a number (between 5 for the strongest and 1 for the weakest). We combined maps for women, men and government officers. We grouped similar causes together into broader categories. We calculated the overall influence of each category on kunika or no-kunika and produced summary maps to communicate findings. The maps identified the strongest causes of kunika as frequent sex, not using modern or traditional contraception, and family dynamics. Women indicated forced sex as an important cause, but men focused on lack of awareness about contraception and fear of side effects. The maps of protective factors mirrored those of the causes. The groups who created the maps approved the summary maps. The maps showed the complex causes of kunika in Bauchi. Promoting contraception is unlikely to be enough on its own to reduce kunika. The summary maps will help local stakeholders to co-design culturally safe ways of reducing kunika.

Communities and service providers address access to perinatal care in postconflict Northern Uganda: socialising evidence for participatory action

Objectives

Describe participatory codesign of interventions to improve access to perinatal care services in Northern Uganda.

Study design

Mixed-methods participatory research to codesign increased access to perinatal care. Fuzzy cognitive mapping, focus groups and a household survey identified and documented the extent of obstructions to access. Deliberative dialogue focused stakeholder discussions of this evidence to address the obstacles to access. Most significant change stories explored the participant experience of this process.

Setting

Three parishes in Nwoya district in the Gulu region, Northern Uganda.

Participants

Purposively sampled groups of women, men, female youth, male youth, community health workers, traditional midwives and service providers. Each of seven stakeholder categories included 5–8 participants in each of three parishes.

Results

Stakeholders identified several obstructions to accessing perinatal care: lack of savings in preparation for childbirth in facility costs, lack of male support and poor service provider attitudes. They suggested joining saving groups, practising saving money and income generation to address the short-term financial shortfall.

They recommended increasing spousal awareness of perinatal care and they proposed improving service provider attitudes. Participants described their own improved care-seeking behaviour and patient–provider relationships as short-term gains of the codesign.

Conclusion

Participatory service improvement is feasible and acceptable in postconflict settings like Northern Uganda. Engaging communities in identifying perinatal service delivery issues and reflecting on local evidence about these issues generate workable community-led solutions and increases trust between community members and service providers.

Participatory Action Research Applied to an Ear, Nose, and Throat Specialty Service Redesign in Remote Australia: A Mixed-Methods Study of Key Stakeholder Perspectives

This mixed-methods study reports on the key stakeholders’ perspectives on the ear, nose, and throat (ENT) service redesign in remote Australia, using a participatory action research (PAR) approach. A primary health care (PHC) clinician survey was conducted to assess local needs and possible educational gaps in clinical knowledge. This was followed by an internal stakeholder forum and a follow-up survey with Torres and Cape Hospital and Health Service staff to gain their perspectives on current service delivery and table ideas for a new ENT health service model. Qualitative data were analyzed inductively and grouped in emerging themes. Quantitative data were imported into tables and analyzed descriptively. PAR allowed for input from 19 PHC clinicians, 10 face-to-face stakeholders perspectives, and 18 stakeholder follow-up survey respondents. Four themes emerged: 1. Training for health workers in ENT management; 2. Improved local service access; 3. New referral pathways to improve continuity of care; and 4. Introduction of telehealth. PAR engaged key stakeholders, identifying gaps in ENT service delivery, and guided the development of the new service model. The inclusion of stakeholders throughout the service redesign process is likely to create a more sustainable model of care which already has local “buy-in”.

Exploring rural patients' understanding of the types, risk factors and measures to prevent healthcare-associated infections in Australia

BACKGROUND

In Australia, there are approximately 165,000 healthcare-associated infections (HAIs) per year. Improving patient knowledge on HAIs and actively involving them in infection prevention is essential. This study assessed patient knowledge on types of and risk factors for HAIs and their perceptions of HAI information provision and hospital infection control practices in rural New South Wales, Australia.

METHODS

Medical and surgical ward patients in three rural hospitals completed a questionnaire between February and March 2019. Open ended responses were grouped under categories, decided upon by two researchers, one of which is an infection prevention and control nurse. Descriptive analysis was completed.

RESULTS

A total of 153 patients completed the survey. Most (n = 126, 82%) participants were previously aware of HAIs, with common sources of education/information being family/friends (n = 55, 36%), television (n = 28, 18%), newspapers (n = 27, 18%), and previous experience of a HAI (n = 20, 13%). Satisfaction with infection control measures and hospital cleanliness was high. Over half (n = 83, 54%) of participants thought they received too little information on HAIs, and only 35% (n = 21) of those that had surgery reported receiving information. Participants suggested that more education for the general public (n = 117, 76%) and patients (n = 110, 72%) in both written form and verbally from hospital staff, and education outside of the hospital in various mediums, could help reduce the risk and rates of HAI.

CONCLUSION

Awareness of HAIs amongst respondents was high, however, education appeared to be lacking. More can be done to inform patient, family and general public education programs in rural and regional Australian hospitals.

Enjeux et solutions en santé mentale et travail : le point de vue des gestionnaires d’une grande organisation de santé

Les problèmes de santé mentale en milieu de travail représentent un enjeu important pour les organismes publics, particulièrement pour les personnes travaillant dans le secteur de la santé, confrontées à de multiples changements suite à la récente réforme du système de santé québécois. Les gestionnaires doivent prendre en considération la santé mentale des employés au sein de leur organisation afin d’assurer leur santé et productivité. Ils sont donc appelés à assumer un rôle incluant la prévention (p. ex. détecter des signes avant-coureurs des problèmes de santé mentale), la gestion d’équipe (p. ex. travailler à la reconnaissance au travail) et l’accompagnement des employés dans leurs tâches lors du retour au travail après une absence maladie due à un trouble mental courant (p. ex. dépression). Bien qu’il existe une littérature foisonnante sur le rôle du gestionnaire dans la prévention des problèmes de santé mentale en milieu de travail et dans le champ de la réadaptation au travail à la suite d’une absence maladie due à un trouble mental courant, à notre connaissance peu de recherches ont été menées sur ces enjeux perçus par les gestionnaires de grandes organisations de santé. En outre, les solutions possibles n’ont pas été explorées dans ce contexte.

Objectif L’objectif de l’étude est de documenter, du point de vue des gestionnaires d’une grande organisation de santé au Québec, les enjeux liés à la santé mentale et travail (de la prévention à la réadaptation) ainsi que les solutions pour y faire face.

Méthode Cette recherche de nature participative consistait en des groupes de discussion avec des gestionnaires sur le thème « santé mentale et travail : enjeux et solutions ». Une analyse thématique a été réalisée. Au total, 83 gestionnaires répartis dans 10 groupes de discussion ont participé à cette étude.

Résultats Des groupes de discussion, 6 grandes catégories conceptuelles ont émergé : 1) le cadre de gestion ; 2) la gestion des ressources humaines, financières, matérielles et informationnelles ; 3) la gestion de la santé mentale et des outils ; 4) la collaboration, les rôles et les actions des parties prenantes ; 5) le sentiment d’appartenance des employés à l’organisation ; 6) l’équilibre entre le travail et la vie privée. De ces grandes catégories conceptuelles, 23 enjeux spécifiques et solutions inhérentes ont émergé.

Conclusions Le consensus qui se dégage de cette étude est qu’il est nécessaire d’avoir accès à une série d’outils (p. ex. un coffre à outils) afin d’aider les gestionnaires à franchir les différentes étapes, de la prévention des problèmes dans leur milieu de travail à la réadaptation et au retour au travail à la suite d’un trouble mental courant. Les résultats ont également souligné la nécessité de mieux définir les rôles de chaque partie prenante dans ce processus. Ces résultats apportent un nouvel éclairage sur les enjeux et solutions potentielles perçus par les gestionnaires d’une grande organisation de santé. Ces résultats pourraient éventuellement être utilisés dans d’autres contextes similaires.

Models of maternal and child healthcare for African refugees: protocol for an exploratory, mixed-methods study

INTRODUCTION

There is a paucity of research examining models of maternal and child health (MCH) care for refugees in high-income countries. Attention has focused on tailoring existing healthcare services to meet the needs of this population and ensure accessible high-quality patient-centred care. This protocol reports the methodology of a study designed to identify models of care for African refugees in New South Wales (NSW), Australia, to determine the evidence for these models and the improvements necessary to best meet service needs that can be delivered in line with available resources, organisational readiness and capacity to implement.

METHODS AND ANALYSIS

This multiphased, participatory research project will employ an exploratory, mixed-methods design. Preparatory activities involve a situational analysis of current MCH services for African refugees and associated policies and guidelines in NSW. We will consult key health service providers and analyse Australian census and settlement data to identify refugee communities and their relation to healthcare services. Phase 1 will ascertain the MCH care needs of African refugees and appropriate service models using: a Delphi survey with health service managers and providers, a nominal group process with African women refugees and; key informant interviews with senior health service managers. This data will be synthesised to provide insight into appropriate models-of-care that could be implemented. These will be discussed in a stakeholder workshop. Phase 2 will comprise a readiness-to-change survey with a selection of providers to explore the willingness, commitment and efficacy of staff members to adopt such models-of-care.

ETHICS AND DISSEMINATION

Ethical approval was granted by NSW Health. Findings will be disseminated to all stakeholders at a knowledge exchange forum to inform the development of a high-quality MCH service delivery model that can be feasibly implemented specifically for African refugee communities.

PROSPERO REGISTRATION NUMBER

CRD42018095564.

Fuzzy cognitive mapping with Inuit women: what needs to change to improve cervical cancer screening in Nunavik, northern Quebec?

Background

Among Canadian Inuit, cervical cancer incidence and mortality rates are up to three times higher than the Canadian average. Cervical cancer is preventable through regular screening which, in Quebec, is opportunistic and requires physical examination and Papanicolaou (“Pap”) smears. Since Human Papillomavirus (HPV) is the necessary cause of cervical cancer, HPV testing is a plausible screening alternative. HPV testing by self-sampling also addresses several barriers associated with physical examination and access to healthcare. In a participatory research paradigm, we worked with two communities of Nunavik to explore the possible implementation of HPV self-sampling.

Method

Key community stakeholders formed an Advisory Committee to guide direct discussions with Inuit women. We presented available facts around cervical cancer, HPV and the female anatomy, and used Fuzzy Cognitive Mapping to collate women’s views. A thematic analysis summarized data, adding links and weights to represent the relationship of each factor on the outcome: screening for cervical cancer.

Results

According to the 27 Inuit women who participated, the most influential factor in using health services was the cultural awareness of the healthcare provider. A significant barrier to screening was patient lack of information. The principal vector of change – the factor most likely to influence other factors – was the means of communication between the healthcare provider and the patient: visual communication was told to be the most effective.

Conclusion

Fuzzy Cognitive Mapping is a practical tool for discussing possible health actions with stakeholders and to inform future research. The tool offers a visual aid for discussion across cultural and educational differences. It can help to build the partnerships that incorporate community voices into co-design of interventions that are relevant to and aligned with the needs of those who use them.