A Transcription and Translation Protocol for Sensitive Cross-Cultural Team Research

A Qualitative Exploration of Spanish-Speaking Latina Women's Experiences Participating in WIC Before and During the COVID-19 Pandemic

BACKGROUND

More than one-third of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants identify as Latino, but participation has been declining and individuals who speak predominantly Spanish face additional barriers to participation. During the COVID-19 pandemic, there were changes in WIC eligibility and benefits that may have been differentially accessible to Spanish-speaking Latina participants due to factors such as language barriers and lack of awareness of changes. Understanding Spanish-speaking Latinas' experiences with the WIC program generally and during the pandemic can inform efforts to equitably implement future emergency food response policies and improve the WIC program and Latina participant enrollment more broadly.

OBJECTIVE

This study aimed to understand the perceptions and experiences of Spanish-speaking Latina WIC participants with the WIC program generally and with COVID-19 pandemic-related policy changes made to the WIC program.

DESIGN

Qualitative in-depth interviews were conducted virtually in Spanish in August 2022 using a semi-structured guide.

PARTICIPANTS/SETTING

Study participants were 18 Spanish-speaking Latina adult WIC participants living in North Carolina recruited using convenience sampling.

ANALYSIS

All interviews were recorded, transcribed, and coded in Spanish. Thematic analysis with inductive coding was used to derive key themes.

RESULTS

Perceptions about the WIC program in this sample were mixed. Participants felt positively about the healthfulness of foods included in the WIC food packages but expressed concern about the monthly benefit amounts being too low and the cultural appropriateness of food options. Pandemic policy changes, such as remote appointments and the Cash Value Benefit increase were perceived positively; however, barriers to using benefits during this time included limited communication from WIC agencies, food shortages, and concerns about not being granted US citizenship or permanent resident status due to use of WIC (ie, public charge rule). Social networks played an important role in learning about and enrolling in WIC and navigating food shortages during the pandemic.

CONCLUSIONS

Concerns about the cultural appropriateness of foods provided, communication challenges, and the public charge rule emphasized the need for resources dedicated in the WIC program to improving Spanish-speaking Latina women's experiences with WIC.

Self-care behaviours of first-generation Chinese immigrants living with cardiovascular disease: A qualitative study

AIM

To identify and describe self-care behaviours performed by Chinese immigrants living with cardiovascular disease in Australia, and factors perceived as barriers and facilitators to evidence-based cardiac self-care.

DESIGN

A qualitative descriptive design.

METHODS

Individual semi-structured phone interviews were conducted among participants meeting the following criteria: (1) first-generation Chinese immigrants to Australia, born in Mainland China, Hong Kong, Macao or Taiwan; (2) Australian permanent residents or citizens; (3) self-reported or medically diagnosed with coronary heart disease, stroke or heart failure; (4) able to speak English or Mandarin; (5) able to provide informed consent, excluding those with history or evidence of impaired cognition such as dementia. Participants were recruited via social media, Chinese community associations and medical centres from September 2021 to June 2022. Data were analysed using inductive and deductive thematic analysis, guided by the Middle-Range Theory of Self-Care of Chronic Illness. The study was reported in line with the COREQ checklist.

RESULTS

Twenty participants were interviewed, 60% female, mean age 69.9 years. Most migrated to Australia at older age following their retirement in China; most had limited English proficiency. Many practiced adequate self-care for their CVD in self-care maintenance and monitoring. Variously, they adopted heart-healthy diets, developed exercise routines, attended medical services and closely monitored their body signs and symptoms. However, self-adjusting medications, taking Traditional Chinese Medicine and self-administering health supplements were prevalent practices and first-response management of acute cardiac symptoms was suboptimal. Linguistic and cultural barriers to obtaining mainstream heart health information meant most participants resorted to informal, anecdotal and mainland Chinese sources.

CONCLUSION

Diverse factors were held responsible for sub-optimal self-care behaviours but lack of access to linguistically and culturally appropriate heart health information was widely blamed. Linguistically and culturally appropriate community-based heart health education programmes are urgently needed, targeting healthy lifestyle modification, medication literacy and cardiac symptom management.

IMPACT

Study findings can be used to improve cardiac nurses' cultural sensitivity and practices targeting Chinese immigrants. Partnering with Chinese community associations offers health service providers and policymakers an innovative route to co-design and deliver targeted heart health education interventions and support for this population.

PUBLIC CONTRIBUTION

Chinese community centre managers contributed to data collection by supporting participant recruitment.

Health information and resources in hospital outpatient waiting areas may not meet the needs of older adults from culturally and linguistically diverse backgrounds: A cross-cultural qualitative study

BACKGROUND

Health information and resources are often provided in hospital outpatient waiting areas but may not meet the cultural and health literacy needs of older adults from culturally and linguistically diverse (CALD) backgrounds.

OBJECTIVES

To explore the perspectives and experiences of Cantonese- and Vietnamese-speaking patients and carers in this setting.

METHODS

This qualitative interview-based study was conducted from December 2019 to March 2020 at a single outpatient rehabilitation service located at a tertiary public hospital. Four adult consumers (two older adult patients, two caregivers) from CALD backgrounds participated in semi-structured interviews with bilingual researchers. Data were transcribed, translated and analysed using reflexive thematic analysis.

RESULTS

Five themes were developed which highlighted that older adults' language profiles shaped their health information needs and ability to access resources in waiting areas. Cultural factors such as filial responsibility may also influence health information preferences.

DISCUSSION

Older consumers from CALD backgrounds did not have equitable access to health information and resources in the waiting area compared with English-literate older adults.

CONCLUSION

Health information and resources in waiting areas warrant improving to better meet the needs of older patients from CALD backgrounds and their caregivers.

Knowledge, perceptions, and practices around zoonotic diseases among actors in the livestock trade in the Lake Victoria crescent ecosystem in East Africa

Background

Zoonotic diseases such as anthrax, rabies, brucellosis, and Rift Valley fever pose a direct threat to health and undercut livelihoods in the communities in which they occur. A combination of anthropogenic and animal activities like migration and interaction with wildlife and their respective parasites and vectors drives the emergence and re-emergence of zoonotic diseases. Consequently, One Health interdisciplinary approaches that incorporate social scientists can provide key insights into complex local perceptions. The approach calls for collaboration between the human and animal health sectors, including the sharing of disease surveillance data necessary to alleviate disease impacts. Livestock traders interact closely with livestock, which puts them at elevated risk of infection and creates conditions by which they may spread zoonotic disease. It is thus essential to examine practices among actors involved in the livestock trade to understand the most appropriate ways to mitigate these risks.

Methods

A qualitative study was conducted among the actors in the livestock trade in Busia County on their knowledge and perceptions of zoonotic diseases and practices that may contribute to the spread, control, and prevention of zoonotic disease transmission. A thematic analysis framework was used to categorize and synthesize data from in-depth interviews (IDIs), key informant interviews (KIIs), and structured observations.

Results

Whereas participants could list livestock diseases, they could not identify which ones were zoonoses, demonstrating insufficient knowledge of zoonosis. They identify sick animals by checking for dropped ears, excess mucus production, diarrhea, bloody urinal discharge, and general animal activity levels. To prevent the spread of these diseases, they wash their animals, isolate sick animals from the rest of the stock, and vaccinate their animals. They seek help from animal health professionals for sick animals as part of curative practices. This shows that they perceive the diseases as serious and that they need to be attended to by professionals. The results also show that they perceive animals from outside the region to be more vulnerable to diseases compared to those from within. The actors in the livestock trade engage in practices like skinning dead animals before burying them; to them, this is a normal practice. Some also consume dead carcasses. These increase the risk of zoonotic disease transmission.

Conclusion

The actors involved in the livestock trade are critical in the prevention and elimination of zoonotic diseases; hence, they need to be involved when developing intervention programs and policies for animal health extension services. Training them as a continuum of animal health workers blends lay and professional knowledge, which, alongside their intense contact with large numbers of animals, becomes a critical disease surveillance tool. Increasing awareness of zoonoses by using multi-disciplinary teams with social scientists is urgently needed so that practices like skinning dead animals before disposing of them and consumption of dead carcasses can be minimized.

Impact of postmenopausal osteoporosis on the lives of Omani women and the use of cultural and religious practises to relieve pain: A hermeneutic phenomenological study

INTRODUCTION

Osteoporosis is a significant clinical and public health concern worldwide. Despite the impact of this condition on women's lives, most studies have focused on its clinical manifestations, drug efficacy, and medical treatment. Furthermore, most studies have been conducted in the West. This study aimed to uncover the personal experiences of postmenopausal Omani women living with osteoporosis.

METHODS

In this interpretive phenomenological study, a purposive sample of 15 postmenopausal Omani women with osteoporosis was recruited from primary and secondary care facilities in Muscat, Oman. Semi-structured one-to-one interviews were conducted via Zoom and telephone because of coronavirus disease 2019 restrictions. The interviews were audio-recorded, and the Ajjawi and Higgs framework was used to analyse the data thematically.

RESULTS

The following key themes were constructed from the interviews: the impact of osteoporosis on religious practices, cultural and social life, and financial status, and the benefits derived from religious and cultural practices and rituals, including Muslim prayer, recitation of Quranic verses, and herbal remedies to cope with osteoporosis-related pain and suffering.

CONCLUSION

Osteoporosis and fragility fractures have a significant impact on the religious, cultural, and financial lives of postmenopausal Omani women with osteoporosis. Muslim prayers, recitation of Quranic verses, and herbal remedies are coping strategies for pain in this population.

PATIENT OR PUBLIC CONTRIBUTION

Postmenopausal Omani women with osteoporosis participated in this study through interviews and contributed their lived experiences. Orthopaedic doctors helped recruit patients with postmenopausal osteoporosis.

Testing the effectiveness of a Fatigue and Activity Management Education for Work (FAME-W) intervention for individuals with inflammatory arthritis: Study protocol for a randomized control trial

BACKGROUND

A work-focused fatigue management intervention, Fatigue and Activity Management Education for Work (FAME-W) programme was developed for individuals with inflammatory arthritis (IA) to manage fatigue in order to maintain demands of their work activities and tasks. This paper presents the protocol for a randomized control trial that will test the effectiveness and acceptability of FAME-W in improving work performance.

METHODS

This protocol presents a multisite randomized control trial and mixed methods process evaluation. Eligible participants will be aged 18-65 years with a diagnosis of inflammatory arthritis and will be in paid employment. The primary outcome of the study will be Work Role Functioning (WRF) questionnaire, and the secondary outcomes will be fatigue, mood, health-related quality of life (HRQOL) and pain. Data will be collected immediately pre- and post-intervention and at 3 months of follow-up. The process evaluation will consist of focus groups and individual interviews to explore participants' experiences of FAME-W. Occupational therapists delivering the programme will complete a facilitator log to assess the fidelity and quality of intervention implementations. Facilitators will participate in individual interviews to explore intervention delivery and acceptability.

RESULTS

Results will be expected to show that FAME-W will improve work performance by helping participants gain self-management strategies around managing fatigue and other symptoms related to fatigue.

CONCLUSION

It is hoped that FAME-W will be an effective and acceptable intervention for individuals with IA in improving work performance by helping them manage their symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05138445, Registered on 30 November 2021.

Health Care Use, Coverage, and Experiences During the Year Prior to Pregnancy in a Primarily Hispanic Population with Low Income: A Descriptive Qualitative Study

INTRODUCTION

A qualitative picture of the health care experiences prior to pregnancy can inform patient-centered strategies to optimize preconception health. This study describes health care utilization and experiences and how health care costs were covered in the year prior to pregnancy in a population of primarily Hispanic women with low income.

METHODS

Pregnant participants were recruited from 5 Federally Qualified Health Center clinics. Semistructured interviews included questions about health care in the year prior to pregnancy. Transcripts were analyzed using a thematic approach that integrated deductive and inductive analysis.

RESULTS

Most participants self-identified as Hispanic. Just under half were US citizens. All but one were Medicaid or Children's Health Insurance Program Perinatal coverage insurance during pregnancy and relied on a variety of strategies to cover prepregnancy health care costs. Almost all received health care during the year prior to pregnancy. Fewer than half reported an annual preventive visit. Health care needs that led to care-seeking included a prior pregnancy, chronic depression, contraception, workplace injury, a persistent rash, screening and treatment for sexually transmitted infection, breast pain, stomach pain (leading to gallbladder removal), and kidney infection. The ways in which study participants covered the costs of health care ranged in terms of sources and complexity. Although some participants described stable health care coverage, most reported changes throughout the year as they pieced together various health care coverage programs and out-of-pocket payments. When participants did seek health care prior to their current pregnancy, most described the experience in positive terms and focused on health care provider communication quality. Respect of patient autonomy was highly valued.

DISCUSSION

Women with pregnancy-related health care coverage accessed care for a wide range of health care needs prior to pregnancy. Health care providers may consider strategies to respectfully introduce preconception care into any visit by an individual who could become pregnant.

Testing the feasibility and acceptability of an online 'Fatigue and Activity Management Education for Work (FAME-W) programme' for individuals with inflammatory arthritis

INTRODUCTION

Fatigue and Activity Management Education for Work (FAME-W) is a four-week, occupational therapy led programme focussing on fatigue management strategies. FAME-W was designed to be delivered in person; however, due to COVID-19 pandemic it was modified to be an online group-based self-management intervention. The purpose of this study was to test the feasibility and acceptability of the online delivery format of FAME-W.

METHODS

This was a mixed methods study. Participants were randomly allocated to intervention or control group. Participants in the intervention group received a four-week online FAME-W. The control group participants received a FAME-W handbook. Participants were required to complete questionnaires on work presenteeism, fatigue, mood, Health Related Quality of Life and pain at baseline, and 3 months post-intervention. Participants in the intervention group attended a focus group immediately following the completion of the programme and the control group participated in individual interviews.

RESULTS

Seven of ten individuals recruited participated in the study. Majority of participants had Rheumatoid Arthritis and were working full-time. The mean age of intervention participants was 53 ± 10.4 and 56.5 ± 3.7 for the controls. All participants in the intervention group had 100% attendance, completed all study measures and activities. Participants had positive comments about the programme format, content, and delivery. Improvements were observed in most measures at follow up.

CONCLUSION

Results suggest that an online programme to improve work ability was feasible and acceptable to individuals with inflammatory arthritis. The online delivery format was favoured over attending a centre-based programme. The findings support a definitive intervention trial of online FAME-W.

Parenting a Toddler in the Era of Pervasive Screens: Interviews with Low-Income Mexican American Parents

Screen media use starts in early childhood, despite recommendations to limit use. This study explored low-income Mexican American mothers' and fathers' beliefs, parenting practices, and perceived contextual contributors related to toddler screen use. We conducted interviews with 32 low-income Mexican American parents. Transcripts of audio recordings were analyzed to identify themes. Parents perceived numerous benefits to screen use, including learning and enjoyment, as well as seeing it as a helpful tool for parents. Reported risks included harmful mental and physical effects and a risk of use being all-consuming. Parents managed screen use with a variety of practices, including giving close attention to content, monitoring duration, and engaging in co-use. They also used screens for behavior management and in specific situations, such as to prepare for sleep. Some differences in beliefs and parenting practices exist by screen device type. Parents also reported that contextual factors, such as weather and neighborhood safety, influenced screen use. This study extends the current literature regarding child screen use, with its focus on low-income Mexican American toddlers. The findings offer interventionists and providers insight into the management of screens in the lives of this population.

Application of Public Health Precautionary Guidelines Before Contracting COVID-19: Lessons Learned from a Qualitative Descriptive Study

Background

The COVID-19 pandemic has affected the Saudi population despite early efforts taken by officials. This study aimed to describe the precautionary measures taken by patients prior to their diagnosis with COVID-19.

Methods

A qualitative descriptive design was employed to collect data from a convenience sample of 26 participants who had COVID-19 and recovered. Data was collected through conducting telephone interviews and was then transcribed and analyzed using inductive content analysis methods adapted from grounded theory.

Results

Data analysis yielded six categories of precautionary measures participants reported using to minimize their risk of contracting COVID-19: (1) wearing a mask, (2) staying at home and avoiding crowds, (3) washing hands and wearing gloves, (4) following social distancing, (5) using sanitizers, and (6) not interacting with anyone.

Conclusion

The discrepancy found between the participants' reported precautionary measures and their actual behavior, as well as the consistency and specificity with which they implemented some and not all measures raise concerns about existing public health messages. The study findings support the importance of well-structured and detailed communication when designing future public health campaigns and data-driven policies.

Screen-related discord and dismay in low-income Mexican American families with toddlers: A qualitative study

PURPOSE

Understanding parental experiences with managing their toddler's screen use is important to inform the design of interventions addressing early childhood screen use, yet current evidence is limited. To enhance our understanding of the context of toddler screen use, this study characterizes the screen-related discord and dismay parents experience in families with toddlers.

DESIGN AND METHODS

In-depth interviews were conducted to explore everyday experiences with screen use among low-income Mexican American caregivers of toddlers (21 mothers, 10 fathers, 1 grandmother). Transcripts were content analyzed to identify prominent themes.

RESULTS

Three themes were identified. Experiences of screen-related discord and dismay arose (1) between parent and child, (2) between parents, and (3) surfaced as parental internal dissonance about toddler screen use. Parent-child discord resulted from parental limit setting and child reactions to parental screen use, which often included tantrums. Parent-partner discord included patterns of agreeing to disagree and direct disagreement between partners. Parents also reported their own feelings of ambivalence and dismay as they struggled to reconcile their preferences against their toddler's actual screen use, while living in a screen-saturated world.

CONCLUSIONS

Findings offer insight into types of screen-related discord and dismay low-income Mexican American parents experience as they attempt to manage their toddler's screen use.

PRACTICE IMPLICATIONS

Although discord in families is normal, the screen-specific discord reported by participants warrants consideration in efforts promoting healthy screen use in families. Providers can tailor their counseling to consider the range of screen-related discord families of toddlers may experience.

Saudi female paramedics' perceptions of challenges in the workplace: A qualitative study

BACKGROUND

It is immensely important that Saudi women become involved in the field of paramedicine in larger numbers; however, anecdotally they continue to experience significant challenges that limit their opportunities for recruitment and deployment in the field. This study set out to explore working female paramedics' perceptions of challenges in their workplace in the Kingdom of Saudi Arabia (KSA).

METHODS

This study utilised a descriptive qualitative approach. Fifteen Saudi female paramedics were recruited to attend one of four focus groups in Riyadh, Saudi Arabia. Data were assessed using thematic analysis.

RESULTS

Three themes emerged from the focus groups that described the perceptions of Saudi female paramedics: personal factors, social factors and employment-related factors. They faced several challenges that could affect their family responsibilities, workplace duties and capacity to work in the field of paramedicine. Saudi society also challenged female paramedics, as the culture and traditions of the KSA limited their participation in the paramedicine workforce. Furthermore, they reported experiencing many employment issues related to recruitment to pre-hospital settings, resulting from organisational policies and procedures.

CONCLUSION

This study investigated the perceptions held by a cohort of female Saudi paramedics of the personal and professional challenges they faced in the workplace in the KSA. The study findings and their implications for female paramedics suggest further research is required to understand the unique challenges they face and to develop various strategies to manage them.

Outsourcing Transcription: Extending Ethical Considerations in Qualitative Research

Research ethics considerations foreground minimising harm to participants. Whilst increasing attention is being paid to researcher vulnerabilities, little has been written about transcriptionists, who can potentially experience emotional distress and vicarious trauma. In this article, we highlight ethical considerations when outsourcing audio for transcription as part of the RE:CURRENT (REcurrent miscarriage: evaluating CURRENT services) Project. Through qualitative interviews, we explored the perspectives of those involved in the management/delivery of services, and women and men who experienced recurrent miscarriage (N = 62). We put distress protocols in place for participants, researchers and the transcriptionist, and adopted a research team approach with the professional transcriber. The transcriptionist highlighted the isolated nature of the role; how researchers often did not brief her when commissioning work, and how the personal impacts of this work were rarely considered. Researchers and ethics committees should consider ethical responsibilities to 'do no harm' when it comes to transcriptionist wellbeing.

Agentic and Receptive Hope: Understanding Hope in the Context of Religiousness and Spirituality through the Narratives of Salvadoran Youth

Hope contributes to positive development in adolescents, and religious and spiritual contexts may be particularly important for developing and supporting hope. However, extant literature on hope, religion, and spirituality neglects their synergistic relation, leaving questions about how they work together to support development. In this study, we explore how religiousness and spirituality (R/S) inform hope by identifying unique synergies that might be particularly useful in difficult contexts. Multilevel qualitative content analyses of interviews conducted with 18 thriving Salvadoran adolescents (50% female, Mage = 16.39 years, SD = 1.83) involved in a faith-based program provided evidence that the ideological and relational resources associated with R/S informed these adolescents’ agentic and receptive hopes. Agentic hopes, identified through expressed hopeful future expectations, revealed that adolescents held beyond-the-self hopes focused on benefiting three distinct targets: God, community, and family. Youth also described “sanctified hopes”, which were hopes focused on fulfilling God’s purposes directly and indirectly. Analyses of receptive hopes, which consider how hope is shaped and empowered by context, revealed that for these youth, hope was experienced in seven key contexts: self, caring adult relationships, family, God, youth development sponsor, social activities, and peers. Implications for fostering hope in R/S contexts within low-to-middle-income countries are discussed.

Prevention and Control of African Swine Fever in the Smallholder Pig Value Chain in Northern Uganda: Thematic Analysis of Stakeholders' Perceptions

African swine fever (ASF) is endemic in Uganda and considered a major constraint to pig production. In the absence of a vaccine, biosecurity is key for ASF prevention and control. To improve prevention and control on farm and community level there is need for more knowledge on current application of biosecurity practises, and better understanding of how pig value chain actors perceive prevention and control. To achieve this, a qualitative interview study involving focus group discussions (FGD) was conducted with actors from the smallholder pig value chain in northern Uganda. Six villages were purposively selected based on previous outbreaks of ASF, preliminary perceived willingness to control ASF, and the representation of several different value chain actors in the village. Results indicated that biosecurity practises such as basic hygiene routines including safe carcass handling, minimising direct and indirect contacts between pigs or between pigs and people, trade restrictions and sharing of disease information were implemented in some of the villages. Thematic analysis based on grounded theory revealed six categories of data relating to ASF prevention and control. Together these categories form a logical framework including both enablers and hindrances for ASF prevention and control. In summary participants mostly had positive perceptions of ASF biosecurity, describing measures as effective. Participants further possessed knowledge of ASF and its transmission, some of which was in line with known scientific knowledge and some not. Nevertheless, participants were hindered from preventing and controlling ASF due to biosecurity costs and a need to prioritise family livelihood over disease transmission risks, incompatibility of current biosecurity practises with local culture, traditions and social contexts and finally lack of access to veterinarians or, occasionally, low-quality veterinary services. The constraints could be addressed by applying participatory processes in designing biosecurity measures to ensure better adaptation to local cultural and social contexts.

"It Is a Full-time Job to Be Ill": Patient Work Involved in Attending Formal Diabetes Care Among Socially Vulnerable Danish Type 2 Diabetes Patients

Previous research has shown social inequality in type 2 diabetes prevalence and that socially vulnerable type 2 diabetes patients benefit less than average from health services. Based on ethnographic fieldwork carried out between February 2017 and March 2018 in a Danish specialized outpatient clinic, this article focuses on patient work among socially vulnerable type 2 diabetes patients. Through attending to the border zone between formal health care and self-care, we show that patients do a lot of work requiring skills, resources, and initiative, to access and benefit from formal care. This work is complex and implicit in the organization of care. Patients' social situations, especially their employment situation, complicate getting patient work done. Attending to patient work and implicit tasks in care organization may help us to see how social inequality in type 2 diabetes outcomes develops, and may be combated.

Barriers and Facilitators to Advance Care Planning among Chinese Patients with Advanced Cancer and Their Caregivers

Background: Chinese American adults experience health disparities at the end of life. Culturally tailored advance care planning (ACP) may promote goal-concordant care across the continuum of serious illness. However, seriously ill Chinese Americans' preferences for ACP remain unknown. Objective: To explore barriers and facilitators to ACP among Chinese patients with advanced cancer and their caregivers. Design: Informed by socioecological theory, we conducted an exploratory qualitative study using semistructured interviews that were thematically analyzed. Setting/Participants: We recruited participants at one U.S. comprehensive cancer center. Of 27 eligible patients approached, we recruited 20 patients (74.1%) and 8 accompanying caregivers. Overall, participants were middle aged (55.6 ± 13.5 years), 60.7% female, 85.7% partnered/married, 89.3% college educated, and had low acculturation (mean Suinn-Lew Asian Self-Identify Acculturation = 2.0 ± 1.6/5.0). More patients were privately insured (35%) than self-pay (30%), Medicare (25%), and Medicaid (10%). Caregivers were split between "spouse" and "child." Results: Findings highlight participants' trust in their clinicians and the study institution as primary supports for clinicians to lead ACP. However, participants' preconceptions of clinicians' professional responsibilities and participants' belief in an uncertain future may hinder an open discussion of goals and values for future medical care. A key moderating factor in how participants view ACP may be their level of acculturation to local care, behavioral, and communication norms. Conclusions: Chinese patients may prefer a routinized clinician-led ACP approach that supports their actionable priorities in the present by leveraging patient-clinician trust, gauging acculturation level, and using indirect communication strategies. Future studies should investigate preferred communication strategies to support in-the-moment care planning.

Spirituality and Spiritual Care among Ethnic Chinese Residing in England: Implications for Nursing

(1) Background: There is a lack of understanding of how spirituality is understood among ethnic Chinese living outside of China. The aim of this investigation was to gain insight into the meaning of spirituality and spiritual care among ethnic Chinese residing in England. (2) Methods: This study employed a grounded theory method. (3) Results: A core category called “seeking a meaningful life” emerged, comprising six categories: “motivation”, “support”, “maintaining standard values”, “achieving a meaningful life”, “relationships” and “perceptions of spirituality”. The core category included a three-stage process influenced by two factors: relationships with others and perceptions of spirituality. In motivated or supported situations of suffering and illness, ethnic Chinese usually follow principles of their Chinese tradition in seeking meaning for a satisfied spiritual life. This process is impacted by their relationships with others and view of spirituality. (4) Conclusions: Participants’ understanding of spirituality and spiritual care was related to seeking meaning and purpose in life. Nurses could incorporate the newly developed life meaning processes into their practice. This could be achieved by culturally explaining suffering and focusing on the significance of physical illness for Chinese people. This would ensure their spiritual care practice delivers culturally competent care for ethnic Chinese. Educators could also incorporate this process within their teaching materials so that this aspect of spiritual care is addressed for this specific group.

Methods, Ethics, and Cross-Language Considerations in Research With Ethnic Minority Children

BACKGROUND

Qualitative research seeking the perspectives of minority children on child health issues such as childhood obesity and healthy weight care is limited, especially in nursing research.

OBJECTIVE

Our objective is to share methodological, ethical, and cross-language knowledge gained from conducting an ethnonursing research study. This study focused on providing a voice for ethnic minority children in childhood obesity literature.

METHODS

The purpose of the study was to discover cultural influences on healthy weight care in children of Burmese refugees of Karen ethnicity. Researchers may exclude children of ethnic minorities from studies because of the distinct challenges in conducting cross-language research and research with children. We critically examine these challenges. The challenge of being a stranger was addressed by a period of immersion in the children's activities prior to data collection, in addition to volunteering as an English teacher with Karen adults. The immersion period was crucial for developing the trust needed in child-inclusive research and research in ethnic minority communities. The challenge of designing an inclusive study with families who experience language barriers was addressed with an interpreter who not only spoke Karen but was also a part of the Karen community. The interpreter provided the authentic sociocultural language equivalence needed for the study's rigor. Ensuring the child's voice was clearly heard was addressed with member checking. Methodological changes necessitated by a pandemic were a distinct challenge discussed in detail.

RESULTS

We described methods useful for nurse researchers seeking transformative knowledge to reduce health disparities in childhood obesity. Nurse researchers may use these methods related to cross-language research and child research for designing research inclusive of minorities with language barriers.

DISCUSSION

The perspectives of children from ethnic minorities are needed to inform culturally congruent healthy weight care for their communities. The goal in providing transparency of the difficulties, successes, and recommendations for methods in research with children of Burmese refugees is to encourage more nurse researchers to work with marginalized groups. Nurse researchers can inform evidence-based, culturally appropriate interventions to address health inequities of minority communities by including the voice of children from these communities.

Reflections of pharmacy students on experiential education in providing health services to people with history of substance use disorders in Malaysia

Introduction: Accreditation standards for pharmacy students’ education include the requirement for experiential education (EE) and acknowledge, in building life-long learning skills, the need to develop students’ skills in analysing their practice-based performance. The goal of this qualitative study was to assess students’ ability to reflect on their experience providing face-to-face care to patients with a history of substance use disorders (PHSUDs). Materials and methods: Interviews were conducted with undergraduate pharmacy students who provided care to PHSUDs in an EE programme. An interview guide was used to explore students’ experiences and their perceptions regarding the challenges they encountered, changes in their attitude towards PHSUDs and ways to improve their ability to care for PHSUDs. Data relevant to the study was extracted from interview transcripts, manually sorted and coded using Microsoft Excel and subjected to thematic analysis.  Results: The themes identified were 1) Increased self-confidence in face-to-face interactions with PHSUDs 2) Increased empathy towards PHSUDS 3) Reduction in stigmatised attitudes towards PHSUDs 4) Positive nature of the interactions with PHSUDs 5) Appreciation for the opportunity to apply knowledge in practice 6) Recognition of the need for improved communication skill training 7) Recognition of the need to improve training for dealing with unexpected questions and situations. Conclusion: Pharmacy students demonstrated reflective skills in identifying multiple positive learning outcomes stemming from a one-day EE programme involving PHSUDs. In addition, they provided insights useful to faculty in curriculum planning.

Do People Agree on How Positive Emotions Are Expressed? A Survey of Four Emotions and Five Modalities Across 11 Cultures

While much is known about how negative emotions are expressed in different modalities, our understanding of the nonverbal expressions of positive emotions remains limited. In the present research, we draw upon disparate lines of theoretical and empirical work on positive emotions, and systematically examine which channels are thought to be used for expressing four positive emotions: feeling moved, gratitude, interest, and triumph. Employing the intersubjective approach, an established method in cross-cultural psychology, we first explored how the four positive emotions were reported to be expressed in two North American community samples (Studies 1a and 1b: n = 1466). We next confirmed the cross-cultural generalizability of our findings by surveying respondents from ten countries that diverged on cultural values (Study 2: n = 1826). Feeling moved was thought to be signaled with facial expressions, gratitude with the use of words, interest with words, face and voice, and triumph with body posture, vocal cues, facial expressions, and words. These findings provide cross-culturally consistent findings of differential expressions across positive emotions. Notably, positive emotions were thought to be expressed via modalities that go beyond the face.

Women's Experiences With Palliative Care During Pregnancy

OBJECTIVE

To explore the experiences of women who received life-limiting fetal diagnoses during pregnancy and support from a perinatal palliative care program.

DESIGN

Descriptive qualitative.

SETTING

The perinatal palliative care program is part of a not-for-profit system of 24 hospitals serving the U.S. Intermountain West region.

PARTICIPANTS

A convenience sample of 12 women who experienced pregnancies with life-limiting fetal diagnoses and received care from a perinatal palliative care program.

METHODS

Women chose to participate from mailed invitations or responded to a post on private social media and then completed semistructured interviews about their experiences surrounding the fetal diagnoses and support from a perinatal palliative care program. Interviews were approximately 40 minutes in length and were conducted over the phone, recorded, and then transcribed. We performed content analysis by coding, forming categories of similar coded data, and constructing themes by recontextualizing categories through iterative, team-based meetings.

RESULTS

We identified four themes from the data: Importance of Memorabilia to Cope With the Death and Documentation of Pregnancy, Acceptance of Death as Part of the Pregnancy Experience, Continued Life Without a Child, and Importance of Empathy Throughout the Process.

CONCLUSION

The themes support the existing research findings about the needs of pregnant women as they cope with difficult situations. Our findings show the necessity and importance of perinatal palliative care programs.

Risk of Secondary Distress for Graduate Students Conducting Qualitative Research on Sensitive Subjects: A Scoping Review of Canadian Dissertations and Theses

Qualitative research, in the methods employed and topics explored, is emotionally demanding. While it is common for ethics protocols to protect research participants from emotional distress, the personal impact of emotional work on the researcher can often go unaddressed. Qualitative researchers, in particular graduate student researchers studying sensitive topics, are at risk of psychological effects. It is unclear, however, how this impact on the researcher is discussed in graduate student work and/or the steps taken to address this risk. To provide an overview of how impact on the researcher is considered in Canadian graduate student research, a comprehensive scoping review of dissertations was conducted. Less than 5% (n = 11) of dissertations reviewed included a plan to mitigate psychological risk to the researcher-suggesting a need for further guidance on minimizing risk of emotional distress. The application of trauma and violence-informed principles to graduate supervision policy and practice is discussed as a promising harm mitigation strategy.

Pelvic Floor Sensations After the First Vaginal Delivery: A Qualitative Study

OBJECTIVES

Current validated instruments to screen for pelvic organ prolapse and its sequelae address bulge symptoms, bowel and bladder changes, and sexual intimacy. However, sensitivity is lower in younger women, and there is no instrument specifically designed to screen in postpartum, primiparous women for early changes, that is, changes that may be noticed before the symptom of a bulge or signs of pelvic organ prolapse occur. Our goal was to elucidate early sensations of pelvic floor support changes in primiparous women after their first vaginal delivery. These could be the focus of future studies differentiating such sensations from a normal postpartum, aiding identification of women for further follow-up.

METHODS

Using comparative focused ethnographic methods, we purposefully sampled and interviewed 17 multiparous women diagnosed with pelvic organ prolapse and 60 primiparous women, half Euro-American and half Mexican American, English or Spanish speaking. Audiotapes were transcribed and then translated. Using inductive coding and matrix analysis, we used constant comparison across transcript data and clustered coded data into body systems-level matrices to arrive at categories of early changes.

RESULTS

We identified early changes by ethnic group in pelvic area sensations and bowel, bladder, and sexual function, including sensations not mentioned in extant questionnaires.

CONCLUSIONS

Early changes may be distressing but difficult for women to introduce in a clinical conversation. Querying these changes may enhance patient-provider communication. Future research is needed to validate these items in questionnaires designed to identify women with persistent early changes that may lead to subsequent objective pelvic organ prolapse.

'The Devil's Company': A Grounded Theory Study on Aging, Loneliness and Social Change Among 'Older Adult Children' in Rural Indonesia

Introduction: As a consequence of rising life expectancies, many families are no longer made up of one, but two simultaneously aging generations. This elderly parent-older adult child (OAC) dyad has emerged as a newly overserved yet little explored demographic phenomenon. Studies on this intergenerational aging dyad and the possible ramifications of when caregivers are simultaneously aging with care-receivers are scarce, especially in low and middle-income countries. This study explored the process by which rural Indonesian OACs experience their own aging, thereby gaining insights into how this newly evolving reality impacts the traditional ways of old-age care provision. Methods: This study has a qualitative design and draws on eight focus group discussions with 48 community-dwelling OACs (23 men, 25 women; mean age 64 years) in four rural villages in the Yogyakarta Special Region, Indonesia. The theoretical framework was largely inspired by symbolic interactionism aided by the sensitizing concepts of social network deficits, interpersonal emotions, and the social construction of risks. Data were analyzed using Grounded Theory as outlined by Corbin and Strauss. Results: Respondents' accounts reflected four categories: 1) aging in a welt of chronic insecurity; 2) OACs: a generation "betwixt and between" expected demands and unmet expectations; 3) landscapes of loneliness; and 4) compromising against conventions. As depicted in a conceptual model, these categories interrelated with each other and were linked by a core category, "bargaining for a sense of security", which collectively summarized a process by which OACs' experienced their own course of aging. Conclusion: Our study provided insights into how and why loneliness emerged amidst the challenges of social and demographic transformations and how in response to this unconventional compromises were made, which affect both the networks of caretakers and the places of old-age care. It is doing so by including the perspectives of rural Indonesian OACs. The results showed how multiple intersecting negative experiences constrained the aging experiences of OACs and produced precarious aging trajectories. Our findings highlight the importance of old-age loneliness as an emerging public health and social problem by discussing how intrinsically this emotion was interwoven with social life.

Family Sense-Making After a Down Syndrome Diagnosis

The script of parenting shifts when parents learn of their child's Down syndrome diagnosis. To build a theory of the diagnostic experience and early family sense-making process, we interviewed 33 parents and nine grandparents living in the United States who learned prenatally or neonatally of their child's diagnosis. The core category of rescuing hope for the future encompassed the social process of sense-making over time as parents managed their sorrow, shock, and grief and amassed meaningful messages that anchored them as they looked toward the future. Application of the theory to practice underscores the import of early professional support offered to parents at key points in the sense-making process: Early as they disclose the news of the diagnosis to family and friends, and later close friends and kin assimilate meaningful messages about what the diagnosis means as they recalibrate expectations for a hopeful future.

Identifying barriers, facilitators, and implementation strategies for a faith-based physical activity program

Background

Community engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community leaders increases the likelihood of successful implementation, scale-up, and sustainment of evidence-based interventions. Faith in Action (Fe en Acción) is an evidence-based promotora-led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women.

Methods

We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of Faith in Action and identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach.

Results

Pastors and church staff described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of physical activity; influence on churchgoers' behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: (1) health behavior change training for pastors and staff, (2) tailored messaging, (3) developing community collaborations, and (4) gaining denominational support.

Conclusions

While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

The Frontline Nurse's Experience of Nursing Outlier Patients

The frontline nurses' experience of nursing with overstretched resources in acute care setting can affect their health and well-being. Little is known about the experience of registered nurses faced with the care of a patient outside their area of expertise. The aim of this paper is to explore the phenomenon of nursing the outlier patient, when patients are nursed in a ward that is not specifically developed to deal with the major clinical diagnosis involved (e.g., renal patient in gynecology ward). Using a hermeneutic phenomenological approach, eleven individual face-to-face in-depth interviews were conducted with registered nurses in New South Wales, Australia. The study identified that each nurse had a specialty construct developed from nursing in a specialized environment. Each nurse had normalized the experience of specialty nursing and had developed a way of thinking and practicing theorized as a "care ladder". By grouping and analyzing various "care ladders" together, the nursing capacities common to nurses formed the phenomenological orientation, namely "the composite care ladder". Compared to nursing specialty-appropriate patients, nursing the outlier patient caused disruption of the care ladder, with some nurses becoming less capable as they were nursing the outlier patient. Nursing the outlier patient disrupted the nurses' normalized constructs of nursing. This study suggests that nursing patients in specialty-appropriate wards will improve patient outcomes and reduce impacts on the nurses' morale.

Conducting a Mixed-Methods Study with Older Adults in Five Languages: Lessons from the Field

One third of older adults in Canada are foreign-born, yet there is a dearth of literature on this population. When our team set out to engage in a mixed-methods study on the physical activity and mobility of foreign-born older adults (FBOAs), we found limited guidance. The objective of this Research Note is to share the lessons that we learned in implementing a mixed-methods study in five languages, with 49 visible minority FBOAs from diverse ethno-cultural groups. With an emphasis on practical implementation, here we share our reflections on early community engagement, linguistic accessibility and literacy considerations, facilitating communication with the research team, creating a support role for multilingual family members, organisational suggestions, and working with interpreters and monolingual transcribers. The older Canadian population is projected to become increasingly diverse in the coming decades, and it is our hope that this note will further facilitate research in this understudied area.

Experiences and lessons learned by genetic counselors in returning secondary genetic findings to patients

Few studies have explored the real-world experiences and strategies of genetic counselors involved in the process of returning secondary findings (SFs). This study aimed to describe and categorize the experiences for the return of SFs from clinical sequencing. Semi-structured telephone interviews with 21 genetic counselors representing 56 incidences were conducted. A content analysis was conducted on the transcripts through an iterative, team-based approach. Four common categories emerged across all interviews. These included (a) the importance of pretest counseling for the return of SFs, (b) how primary test results influenced the level of importance placed on the SFs, (c) patients' emotional reactions from receiving SF results, and (d) how returning SFs changed future pretest counseling and consent. This study identified experiences and common practices by genetic counselors who returned SFs. More research is needed to assess how genetic counselors' specific strategies improve patient comprehension and medical actions.

Prevention of Lower Urinary Tract Symptoms Research Consortium Focus Group Study of Habits, Attitudes, Realities, and Experiences of Bladder Health

AIM

The study purpose is to explore adolescent and adult women's experiences, perceptions, beliefs, knowledge and behaviors related to bladder health across the life course using a socioecological perspective. Lower urinary tract symptoms affect between 20-40% of young adult to middle-aged women, with symptoms increasing in incidence and severity with aging. There is limited evidence to address bladder health promotion and prevention of dysfunction. This first study of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium is designed to address gaps in existing qualitative research in this area.

DESIGN

This focus group study will be implemented across seven geographically diverse United States research centers using a semi-structured focus group guide informed by a conceptual framework based on the socioecological model.

METHODS

The study was approved in July 2017. A total of 44 focus groups composed of 6-8 participants representing six different age categories (ranging from 11 to over 65 years) will be completed. We aim to recruit participants with diverse demographic and personal characteristics including race, ethnicity, education, socioeconomic status, urban/rural residence, physical/health conditions and urinary symptom experience. Up to 10 of these focus groups will be conducted in Spanish. Focus group transcripts will undergo content analysis and data interpretation to identify and classify themes and articulate emerging themes.

DISCUSSION

This foundational qualitative study seeks to develop an evidence base to inform future research on bladder health promotion in adolescent and adult women.

IMPACT

This study has the potential to provide new insights and understanding into adolescent and adult women's lived experience of bladder health, the experience of lower urinary symptoms and knowledge and beliefs across the life course. This article is protected by copyright. All rights reserved.

An Ecocultural Perspective on Eating-Related Routines Among Low-Income Families With Preschool-Aged Children

Eating-related routines, such as regular mealtimes, can protect against obesity. Little is known about eating-related routines among preschoolers or the factors that shape those routines. Ecocultural Theory and qualitative interviews with 30 caregivers of preschoolers in Colorado were used to describe eating-related routines at home and parents' perspectives on the factors that shape routines. Qualitative content analysis was used to analyze and interpret data. Consistent with clinical recommendations, parents' goals included dinner meals where adults and preschoolers eat the same food, in the same place, at the same time. However, parents' employment schedules and challenges in managing preschoolers' behavior prevented parents from consistently enacting recommended routines. Educating parents alone may not be sufficient to ensure optimal eating-related routines among preschoolers, and the household context needs to be considered. Families organized routines according to cultural values and available resources.

Strategies for overcoming language barriers in research

AIM

This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier.

DESIGN

Discussion paper.

DATA SOURCES

Research methods papers addressing cross-language research issues published between 2000-2017.

IMPLICATIONS FOR NURSING

Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into "big data" systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes.

CONCLUSION

Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research.

IMPACT

This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.

Provision and uptake of routine antenatal services: a qualitative evidence synthesis

BACKGROUND

Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.

OBJECTIVES

To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.

SEARCH METHODS

To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.

SELECTION CRITERIA

We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.

DATA COLLECTION AND ANALYSIS

Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.

MAIN RESULTS

We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.

AUTHORS' CONCLUSIONS

This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

Mobile Device Use Among Rural, Low-Income Families and the Feasibility of an App to Encourage Preschoolers' Physical Activity: Qualitative Study

BACKGROUND

As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, questions remain about the feasibility and acceptability of intervention delivery via mobile apps in low-income, rural settings and among families with preschoolers.

OBJECTIVE

The aims of this study were to understand the content and context of mobile device use for preschoolers; explore parent beliefs on this topic, including the acceptability of intervention delivery via mobile devices; and test a prototype of an app to encourage preschoolers' physical activity with both parents and children.

METHODS

Parents (n=29) were recruited from 5 preschool centers in eastern, rural Colorado to complete a semistructured telephone interview regarding preschoolers' mobile device use. A second sample of parents (n=31) was recruited from the same preschool centers to view the app prototype independently and provide feedback. A third sample of preschool children (n=24) was videotaped using the app in small groups to measure engagement and record their responses to the app.

RESULTS

Five key content areas emerged from the telephone interviews: (1) mobile devices are an important part of families' everyday routines, and parents have parameters governing their use; (2) parents often use mobile devices as a tool for behavior management; (3) parents clearly distinguish between mobile device use for learning versus entertainment; (4) parents have an overarching desire for balance in regard to their child's mobile device use; and (5) parents were generally supportive of the idea of using mobile apps for intervention delivery. From the app prototype testing with parents, participants reacted positively to the app and felt that it would be useful in a variety of situations. Testing with preschoolers showed the children were highly engaged with the app and a majority remained standing and/or actively moving through the entire length of the app.

CONCLUSIONS

Mobile devices are already integrated into most families' daily routines and appear to be an acceptable method of intervention delivery in low-income families in rural Colorado. The physical activity app represents an innovative way to reach these families and, with further improvements based on participant feedback, will provide children with a unique opportunity to practice key movement skills.

Deaf Qualitative Health Research: Leveraging Technology to Conduct Linguistically and Sociopolitically Appropriate Methods of Inquiry

One of the most understudied health disparity populations in the United States is the Deaf community-a sociolinguistic minority group of at least 500,000 individuals who communicate using American Sign Language. Research within this population is lacking, in part, due to researchers' use of methodologies that are inaccessible to Deaf sign language users. Traditional qualitative methods were developed to collect and analyze participants' spoken language. There is, therefore, a paradigm shift that must occur to move from an auditory data schema to one that prioritizes the collection and analysis of visual data. To effectively navigate this shift when working with Deaf sign language users, there are unique linguistic and sociopolitical considerations that should be taken into account. The current article explores these considerations and outlines an emerging method of conducting qualitative analysis that, we argue, has the potential to enhance qualitative researchers' work regardless of the population of focus.

HEROs: Design of a Mixed-Methods Formative Research Phase for an Ecocultural Intervention to Promote Healthy Eating and Activity Behaviors in Rural Families With Preschoolers

OBJECTIVE

To describe the mixed-methods formative research phase in the development of the Healthy Environments Study (HEROs), a technology-based, interactive family intervention to promote healthy eating and activity behaviors for young children in the home environment.

DESIGN

A mixed-method iterative approach, using ecocultural theory as a framework, will guide the development of both quantitative and qualitative formative research assessments.

SETTING

Rural eastern Colorado.

PARTICIPANTS

Low-income families (n = 200) with preschool-aged children enrolled at 6 Head Start/preschool centers.

MAIN OUTCOME MEASURES

Quantitative and qualitative methodologies will garner insights into 4 key topic areas: (1) food behaviors and environments (Remote Food Photography Method, parent focus group, and survey), (2) physical activity behaviors and environments (parent interview and survey), (3) mobile device use (parent survey and interview), and (4) daily life (ecocultural family interview and teacher/staff group discussions).

ANALYSIS

Results will be interpreted in combination to allow for a holistic understanding of participant behaviors, beliefs, attitudes and values related to each of the 4 topic areas. Collectively, outcomes will provide a comprehensive picture of preschoolers' daily life and inform intervention design and strategies to enhance preschoolers' eating and activity behaviors in the home environment.

Linguistic Conceptualizations of Disease Among the Luo of Kenya

The region inhabited by the Luo ethnic group in Kenya is disease endemic. However, disease awareness initiatives register low acceptance due to the sociocultural images of disease and illness conceptualized in the local Dholuo language in ways that may contradict modern biomedical knowledge and practice. This article evaluates the sociocultural basis of encoding descriptions of disease in the Luo indigenous knowledge system and their implications for modern medical practice. The methodology entailed use of qualitative interviews of purposively sampled Dholuo-speaking patient escorts in a provincial referral hospital. Nonparticipant observation was also conducted at funerals to monitor contextualized usage of the discourse of disease, illness, and death. The data were analyzed using qualitative content analysis and categorized into emergent themes and categories. The results revealed that Dholuo is replete with expressions that emphasize the vulnerability and discrimination of the sick. Such attitudes cause rejection of interventions and negatively influence health-seeking behavior. The expressions were relevant and acceptable to cultural insiders; hence, they could determine their understanding of health conditions thereby influencing how they make medical decisions. It emerges that the unique Luo worldview controls their perceptions on the causes of disease and prescribes community-driven remedies which may depart from the expectations of the biomedical model.