Implementation, Mechanisms and Context of the MAMAACT Intervention to Reduce Ethnic and Social Disparity in Stillbirth and Infant Health

Cultural Competence Interventions in European Healthcare: A Scoping Review

Europe is undergoing rapid social change and is distinguished by its cultural superdiversity. Healthcare is facing an increasing need for professionals to adapt to this environment. Thus, the promotion of cultural competence in healthcare has become a priority. However, the training being developed and their suitability for the European context are not well known. The aim of this qualitative study has been to map the scientific literature in order to comprehend the current state of research on this topic. For this purpose, we conducted a systematic scoping review of the empirical publications focused on cultural competence interventions for healthcare professionals in European countries. The search was conducted in eight thematic (PsycINFO, MedLine, and PubPsych) and multidisciplinary databases (Academic Search Ultimate, E-Journals, Scopus, ProQuest, and Web of Science) to identify relevant publications up to 2023. Results were presented qualitatively. Out of the initial 6506 records screened, a total of 63 publications were included. Although the interventions were implemented in 23 different European countries, cultural competence interventions have not been widely adopted in Europe. Significant heterogeneity was observed in the conception and operacionalización of cultural competence models and in the implementation of the interventions. The interventions have mostly aimed at improving healthcare for minority population groups and have focused on the racial and ethnic dimensions of the individual. Future research is needed to contribute to the conceptual development of cultural competence to design programs tailored to European superdiversity. This scoping review has been registered in OSF and is available for consultation.

Midwives' Intercultural Effectiveness Levels and Influencing Factors

INTRODUCTION

Due to globalization, countries around the world are starting to notice diversity in their populations. It is crucial that midwives be able to communicate effectively with women from a variety of cultures to provide them with culturally effective health care.

METHOD

This cross-sectional study was conducted with 394 midwives who work in seven different regions of Türkiye. Data on the intercultural effectiveness and intercultural communication competence of midwives were collected. Data analysis was performed using descriptive statistics, t-tests, analysis of variance, and regression analysis.

RESULTS

Midwives' intercultural effectiveness was influenced by their foreign language proficiency, experiences abroad, having friends from different cultures, following social media platforms in different languages and cultures, providing care to individuals from diverse cultures, and their willingness to do so.

DISCUSSION

Findings suggest that exposure to different cultures enhances the level of intercultural effectiveness. Consequently, it is recommended to make plans to support midwives to have positive experiences with different cultures.

Unlocking the mechanisms of change in the MAMAACT intervention to reduce ethnic disparity in stillbirth and newborns' health: integration of evaluation findings

Ethnic disparities in stillbirth exist in Europe and suboptimal care due to miscommunication is one contributing cause. The MAMAACT intervention aimed to reduce ethnic disparity in stillbirth and newborns' health through improved management of pregnancy complications. The intervention encompassed training of antenatal care midwives in cultural competencies and intercultural communication combined with health education materials for the expecting parents about symptoms of pregnancy complications. The evaluation consisted of a qualitative in-depth implementation analysis and a process evaluation embedded in a cluster randomized trial including 19 of 20 maternity wards in Denmark. In this article, the findings from the different evaluation perspectives are integrated. The integration follows the principles of realist evaluation by analyzing to what extent the MAMAACT activities were generating mechanisms of change in interaction with the context. The integration analysis shows that the health education materials in the MAMAACT intervention contributed to heightened health literacy concerning pregnancy complications among pregnant women. Additionally, the training of midwives in cultural competency and intercultural communication raised awareness among midwives. Nonetheless, the exclusive emphasis on midwives and the inflexibility in care provision hindered them from changing their communication practices. To enhance the cultural competence in maternity care, it is essential to implement more comprehensive initiatives involving healthcare professionals in maternity care at all levels, from pregraduate to postgraduate. Adequate interpreter services and management support should also be ensured. Currently, the Danish antenatal care system faces challenges including inadequate information transfer between healthcare sectors, insufficient differentiation of care, and inflexibility in midwife scheduling. This results in a lack of responsiveness to the individual needs of women with immigrant backgrounds, potentially reproducing health inequities.

Interventions to improve migrants' access to sexual and reproductive health services: a scoping review

INTRODUCTION

Migrants' access to sexual and reproductive health (SRH) services is constrained by several individual, organisational and structural barriers. To address these barriers, many interventions have been developed and implemented worldwide to facilitate the access and utilisation of SRH services for migrant populations. The aim of this scoping review was to identify the characteristics and scope of interventions, their underlying theory of change, reported outcomes and key enablers and challenges to improve access to SRH services for migrants.

METHODS

A scoping review was conducted according to the Arksey and O'Malley (2005) guidelines. We searched three electronic databases (MEDLINE, Scopus and Google Scholar) and carried out additional searches using manual searching and citations tracking of empirical studies addressing interventions aimed at improving access and utilisation of SRH services for migrant populations published in Arabic, French or English between 4 September 1997 and 31 December 2022.

RESULTS

We screened a total of 4267 papers, and 47 papers met our inclusion criteria. We identified different forms of interventions: comprehensive (multiple individual, organisational and structural components) and focused interventions addressing specific individual attributes (knowledge, attitude, perceptions and behaviours). Comprehensive interventions also address structural and organisational barriers (ie, the ability to pay). The results suggest that coconstruction of interventions enables the building of contextual sensitive educational contents and improved communication and self-empowerment as well as self-efficacy of migrant populations, and thus improved access to SRH.

CONCLUSION

More attention needs to be placed on participative approaches in developing interventions for migrants to improve access to SRH services.

Effectiveness evaluation of an antenatal care intervention addressing disparities to improve perinatal outcomes in Denmark: A nationwide register-based analysis of a cluster randomised controlled trial (MAMAACT)

OBJECTIVE

To evaluate whether MAMAACT, an antenatal care (ANC) intervention, aimed at reducing ethnic and social disparities in perinatal mortality, affected perinatal health outcomes.

DESIGN

Cluster randomised controlled trial.

SETTING

Nineteen of 20 maternity wards in Denmark.

POPULATION

All newborn children within a pre-implementation period (2014-2017) or an implementation period (2018-2019) (n = 188 658).

INTERVENTION

A 6-h training session for midwives in intercultural communication and cultural competence, two follow-up dialogue meetings, and health education materials for pregnant women on warning signs of pregnancy complications in six languages.

METHODS

Nationwide register-based analysis of the MAMAACT cluster randomised controlled trial. Mixed-effects logistic regression models were used to estimate the change in outcomes from pre- to post-implementation in the intervention group relative to the control group. Results were obtained for the overall study population and for children born to immigrants from low- to middle-income countries, separately. Models were adjusted for confounders selected a priori.

MAIN OUTCOME MEASURES

A composite perinatal mortality and morbidity outcome, including stillbirths, neonatal deaths, Apgar score <7, umbilical arterial pH < 7.0, admissions to a neonatal intensive care unit (NICU) >48 h, and NICU admissions for mechanical ventilation. Additional outcomes were the individual measures.

RESULTS

The intervention increased the risk of the composite outcome (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 0.99-1.34), mainly driven by differences in NICU admission risk (composite outcome excluding NICU, aOR 0.98, 95% CI 0.84-1.14). The intervention slightly increased the risk of low Apgar score and decreased the risk of low arterial pH, reflecting, however, small differences in absolute numbers. Other outcomes were unchanged.

CONCLUSIONS

Overall, the MAMAACT intervention did not improve the composite perinatal mortality and morbidity outcome (when excluding NICU admissions). The lack of effects may be due to contextual factors including organisational barriers in ANC hindering the midwives from changing practices.

Evidence in public health: An integrated, multidisciplinary concept

AIMS

Traditionally, evidence in public health has been founded in health sciences using the hierarchy of evidence. In this Commentary, we argue that we need a combination of evidence based on a broad range of scientific disciplines and methodologies to best translate research into improved public health.

METHODS

Using existing concepts of evidence such as the hierarchy of evidence and the evidence typology, we discuss their pitfalls in public health science and suggest a way forward. We use the case of the MAMAACT intervention to exemplify our claims.

RESULTS

Public health does not apply an either/or perspective, but an integrated, theoretically informed approach based on mixed and multiple methods to understand complex health problems and how to tackle them. Ideally, public health decisions should always incorporate scientific evidence, although we need to fully acknowledge that the quality of evidence is defined by more than just being placed highest in the hierarchy of evidence. No method or study design is superior in obtaining evidence, but we need the combined and supplemented contributions from a range of scientific approaches to form a whole. Thus, we propose an integrated, multidisciplinary concept of evidence in the form of cogwheels, where the public health problem followed by the research question(s) will guide the components to be studied and the use of method(s) in an interplay with the decisions of the scientific perspective(s) that include choice of theories.

CONCLUSIONS

We cannot understand or solve public health challenges without multidisciplinary approaches in a complimentary formation.