Grounding evidence in experience to support people-centered health services

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.

Fuzzy Cognitive Map Applications in Medicine over the Last Two Decades: A Review Study

Fuzzy Cognitive Maps (FCMs) have become an invaluable tool for healthcare providers because they can capture intricate associations among variables and generate precise predictions. FCMs have demonstrated their utility in diverse medical applications, from disease diagnosis to treatment planning and prognosis prediction. Their ability to model complex relationships between symptoms, biomarkers, risk factors, and treatments has enabled healthcare providers to make informed decisions, leading to better patient outcomes. This review article provides a thorough synopsis of using FCMs within the medical domain. A systematic examination of pertinent literature spanning the last two decades forms the basis of this overview, specifically delineating the diverse applications of FCMs in medical realms, including decision-making, diagnosis, prognosis, treatment optimisation, risk assessment, and pharmacovigilance. The limitations inherent in FCMs are also scrutinised, and avenues for potential future research and application are explored.

iSupport-Brasil: Cross-cultural adaptation of the content included in the iSupport program for caregivers of people who have dementia

OBJECTIVE

Examine the process of culturally adapting the content of the World Health Organization iSupport program for family caregivers of people living with dementia in Brazil.

METHOD

This is a multicenter and methodological study to cross-culturally adapt the iSupport program. Initially, the content of the iSupport program was translated into Brazilian Portuguese by professional translator trained in Psychology, with mastery of the original language of the content (English). Focus groups were then held with caregivers/former caregivers of people who have dementia (n = 24) and health professionals specialized in aging (n = 24). The participants had access to part of the iSupport material for analysis purposes. Semi-structured interviews were conducted between June and September 2019. All the interviews were recorded and transcribed in full for subsequent analysis. All the ethical aspects were respected.

RESULTS

The translator implemented some cross-cultural adaptations, such as substituting 69 proper names used in the original version by names of different Brazilian regions. In relation to the analysis of the material and comments from the focus groups, in general, all the participants had positive opinions about the material included in iSupport. Some changes were suggested in relation to the terminology and examples given in the modules to better fit the Brazilian culture and health systems, and links to relevant pages of the local Alzheimer's association were included. All the linguistic and cultural adaptations proposed were systematically documented and duly justified in structured forms provided by the World Health Organization, which approved all of them after verification of fidelity.

CONCLUSION

The product of this research is the first version of the iSupport-Brasil program and the inclusion of its content in a digital platform. For the most part, the content offered in iSupport proved to be an important online tool to provide support and diverse information to the caregivers of people who have dementia.

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.

Knowledge translation resources to support the use of quality of life assessment tools for the care of older adults living at home and their family caregivers

Purpose

To support the use of quality of life (QOL) assessment tools for older adults, we developed knowledge translation (KT) resources tailored for four audiences: (1) older adults and their family caregivers (micro), (2) healthcare providers (micro), (3) healthcare managers and leaders (meso), and (4) government leaders and decision-makers (macro). Our objectives were to (1) describe knowledge gaps and resources and (2) develop corresponding tailored KT resources to support use of QOL assessment tools by each of the micro-, meso-, and macro-audiences.

Methods

Data were collected in two phases through semi-structured interviews/focus groups with the four audiences in Canada. Data were analyzed using qualitative description analysis. KT resources were iteratively refined through formative evaluation.

Results

Older adults and family caregivers (N = 12) wanted basic knowledge about what “QOL assessment” meant and how it could improve their care. Healthcare providers (N = 13) needed practical solutions on how to integrate QOL assessment tools in their practice. Healthcare managers and leaders (N = 14) desired information about using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) in healthcare programs and quality improvement. Government leaders and decision-makers (N = 11) needed to know how to access, use, and interpret PROM and PREM information for decision-making purposes. Based on these insights and evidence-based sources, we developed KT resources to introduce QOL assessment through 8 infographic brochures, 1 whiteboard animation, 1 live-action video, and a webpage.

Conclusion

Our study affirms the need to tailor KT resources on QOL assessment for different audiences. Our KT resources are available: www.healthyqol.com/older-adults.

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.

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.

Childbirth evacuation among rural and remote Indigenous communities in Canada: A scoping review

PROBLEM

Routine evacuation of pregnant Indigenous women from remote regions to urban centres for childbirth is a central strategy for addressing maternal health disparities in Canada. Maternal evacuation continues despite mounting evidence of its negative impacts on Indigenous women and families.

BACKGROUND

Since the 1960s, pregnant Indigenous women living in remote regions in Canada have been transferred to urban hospitals for childbirth. In the following decades, evidence emerged linking maternal evacuation with negative impacts on Indigenous women, their families, and communities. In some communities, resistance to evacuation and the creation of local birthing facilities has resulted in highly diverse experiences of childbirth and evacuation.

AIM

A scoping review mapped the evidence on maternal evacuation of Indigenous women in Canada and its associated factors and outcomes from 1978 to 2019.

METHODS

We searched MEDLINE, Embase, and CINAHL, and grey literature from governmental and Indigenous organizations. We collated the evidence on maternal evacuation into 12 themes.

RESULTS

Factors related to evacuation include (a) evacuation policies (b) institutional coercion (c) remoteness and (d) maternal-fetal health status. Evacuation-related outcomes include (e) maternal-child health impacts (f) women's experience of evacuation (g) financial hardships (h) family disruption (i) cultural continuity and community wellness (ij) engagement with health services (k) self-determination, and (l) quality of health services.

DISCUSSION

Numerous emotional, social and cultural harms are associated with evacuation of Indigenous women in Canada. Little is known about the long-term impacts of evacuation on Indigenous maternal-infant health. Evidence on evacuation from remote Métis communities remains a critical knowledge gap.

Factors influencing maternal health in indigenous communities with presence of traditional midwifery in the Americas: protocol for a scoping review

INTRODUCTION

Indigenous mothers often receive culturally unsafe services that do not fully respond to their needs. The objective of this scoping review is to collate and assess evidence that identifies factors, including the role and influence of traditional midwives, that affect maternal health in indigenous communities in the Americas. The results will map Western perspectives reflected in published and unpublished literature to indicate the complex network of factors that influence maternal outcomes. These maps will allow for comparison with local stakeholder knowledge and discussion to identify what needs to change to promote culturally safe care.

METHODS AND ANALYSIS

A librarian will search studies with iterative and documented adjustments in CINAHL, Scopus, Latin American and Caribbean Health Sciences Literature (LILACS), MEDLINE, Embase and Google Scholar without any time restrictions, and use Google search engine for grey literature. Included studies will be empirical (quantitative, qualitative or mixed); address maternal health issues among indigenous communities in the Americas; and report on the role or influence of traditional midwives. Two researchers will independently screen and blindly select the included studies. The quality assessment of included manuscripts will rely on the Mixed Methods Appraisal Tool (MMAT). Two independent researchers will extract data on factors promoting or reducing maternal health in indigenous communities, including the role or influence of traditional midwives. Fuzzy cognitive mapping will summarise the findings as a list of relationships between identified factors and outcomes with weights indicating strength of the relationship and the evidence supporting this.

ETHICS AND DISSEMINATION

This review is part of a proposal approved by the ethics committees at McGill University and the Centro de Investigación de Enfermedades Tropicales in Guerrero. Participating indigenous communities in Guerrero State approved the study in 2015. The results of the scoping review will contribute to the field of cultural safety and intercultural dialogue for the promotion of maternal health in indigenous communities.

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.

Fuzzy cognitive mapping and soft models of indigenous knowledge on maternal health in Guerrero, Mexico

Background

Effective health care requires services that are responsive to local needs and contexts. Achieving this in indigenous settings implies communication between traditional and conventional medicine perspectives. Adequate interaction is especially relevant for maternal health because cultural practices have a notable role during pregnancy, childbirth and the postpartum period. Our work with indigenous communities in the Mexican state of Guerrero used fuzzy cognitive mapping to identify actionable factors for maternal health from the perspective of traditional midwives.

Methods

We worked with twenty-nine indigenous women and men whose communities recognized them as traditional midwives. A group session for each ethnicity explored risks and protective factors for maternal health among the Me’phaa and Nancue ñomndaa midwives. Participants mapped factors associated with maternal health and weighted the influence of each factor on others. Transitive closure summarized the overall influence of each node with all other factors in the map. Using categories set in discussions with the midwives, the authors condensed the relationships with thematic analysis. The composite map combined categories in the Me’phaa and the Nancue ñomndaa maps.

Results

Traditional midwives in this setting attend to pregnant women’s physical, mental, and spiritual conditions and the corresponding conditions of their offspring and family. The maps described a complex web of cultural interpretations of disease – “frío” (cold or coldness of the womb), “espanto” (fright), and “coraje” (anger) – abandonment of traditional practices of self-care, women’s mental health, and gender violence as influential risk factors. Protective factors included increased male involvement in maternal health (having a caring, working, and loving husband), receiving support from traditional healers, following protective rituals, and better nutrition.

Conclusions

The maps offer a visual language to present and to discuss indigenous knowledge and to incorporate participant voices into research and decision making. Factors with higher perceived influence in the eyes of the indigenous groups could be a starting point for additional research. Contrasting these maps with other stakeholder views can inform theories of change and support co-design of culturally appropriate interventions.

Fuzzy cognitive mapping: An old tool with new uses in nursing research

AIMS

Describe the implementation and uses of fuzzy cognitive mapping (FCM) as a constructive method for meeting the unique and rapidly evolving needs of nursing inquiry and practice.

DESIGN

Discussion paper.

DATA SOURCES

Drawing on published scholarship of cognitive mapping from the fields of ecological management, information technology, economics, organizational behaviour and health development, we consider how FCM can contribute to contemporary challenges and aspirations of nursing research.

IMPLICATIONS FOR NURSING

Fuzzy cognitive mapping can generate theory, describe knowledge systems in comparable terms and inform questionnaire design and dialogue. It can help build participant-researcher partnerships, elevate marginalized voices and facilitate intercultural dialogue. As a relatively culturally safe and foundational approach in participatory research, we suggest that FCM should be used in settings of transcultural nursing, patient engagement, person- and family-centred care and research with marginalized populations. FCM is amenable to rigorous analysis and simultaneously allows for greater participation of stakeholders.

CONCLUSION

In highly complex healthcare contexts, FCM can act as a common language for defining challenges and articulating solutions identified within the nursing discipline.

IMPACT

There is a need to reconcile diverse sources of knowledge to meeting the needs of nursing inquiry. FCM can generate theory, describe knowledge systems, facilitate dialogue and support questionnaire design. In its capacity to engage multiple perspectives in defining problems and identifying solutions, FCM can contribute to advancing nursing research and practice.