What Influences Saturation? Estimating Sample Sizes in Focus Group Research

Saturation is commonly used to determine sample sizes in qualitative research, yet there is little guidance on what influences saturation. We aimed to assess saturation and identify parameters to estimate sample sizes for focus group studies in advance of data collection. We used two approaches to assess saturation in data from 10 focus group discussions. Four focus groups were sufficient to identify a range of new issues (code saturation), but more groups were needed to fully understand these issues (meaning saturation). Group stratification influenced meaning saturation, whereby one focus group per stratum was needed to identify issues; two groups per stratum provided a more comprehensive understanding of issues, but more groups per stratum provided little additional benefit. We identify six parameters influencing saturation in focus group data: study purpose, type of codes, group stratification, number of groups per stratum, and type and degree of saturation.

'Will I be able to have a baby?' Results from online focus group discussions with childhood cancer survivors in Sweden

STUDY QUESTION

What do adolescent and young adult survivors of childhood cancer think about the risk of being infertile?

SUMMARY ANSWER

The potential infertility, as well as the experience of having had cancer, affects well-being, intimate relationships and the desire to have children in the future.

WHAT IS KNOWN ALREADY

Many childhood cancer survivors want to have children and worry about possible infertility.

STUDY DESIGN, SIZE, DURATION

For this qualitative study with a cross-sectional design, data were collected through 39 online focus group discussions during 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cancer survivors previously treated for selected diagnoses were identified from The Swedish Childhood Cancer Register (16–24 years old at inclusion, ≥5 years after diagnosis) and approached regarding study participation. Online focus group discussions of mixed sex (n = 133) were performed on a chat platform in real time. Texts from the group discussions were analysed using qualitative content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The analysis resulted in the main category Is it possible to have a baby? including five generic categories: Risk of infertility affects well-being, Dealing with possible infertility, Disclosure of possible infertility is a challenge, Issues related to heredity and Parenthood may be affected. The risk of infertility was described as having a negative impact on well-being and intimate relationships. Furthermore, the participants described hesitation about becoming a parent due to perceived or anticipated physical and psychological consequences of having had cancer.

LIMITATIONS, REASONS FOR CAUTION

Given the sensitive topic of the study, the response rate (36%) is considered acceptable. The sample included participants who varied with regard to received fertility-related information, current fertility status and concerns related to the risk of being infertile.

WIDER IMPLICATIONS OF THE FINDINGS

The results may be transferred to similar contexts with other groups of patients of childbearing age and a risk of impaired fertility due to disease. The findings imply that achieving parenthood, whether or not with biological children, is an area that needs to be addressed by health care services.

STUDY FUNDING/COMPETING INTEREST(S)

The study was financially supported by The Cancer Research Foundations of Radiumhemmet, The Swedish Childhood Cancer Foundation and the Doctoral School in Health Care Science, Karolinska Institutet. The authors report no conflicts of interest.

Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study

BACKGROUND

Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women's and men's life prospects.

OBJECTIVE

The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men's and women's life circumstances.

DESIGN

Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied.

FINDINGS

TWO MAJOR THEMES EMERGED DURING ANALYSIS: 'Reiteration of gender roles' and 'Agents of change'. The first theme included perceptions of traditional gender roles and how these preserve women's subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation.

CONCLUSIONS

This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women's empowerment.

Experiences of pregnancy and motherhood among teenage mothers in a suburb of Accra, Ghana: a qualitative study

BACKGROUND

The proportion of teenage girls who are mothers or who are currently pregnant in sub-Saharan African countries is staggering. There are many studies regarding teenage pregnancy, unsafe abortions, and family planning among teenagers, but very little is known about what happens after pregnancy, ie, the experience of teenage motherhood. Several studies in Ghana have identified the determinants of early sexual activity, contraception, and unsafe abortion, with teenage motherhood only mentioned in passing. Few studies have explored the experiences of adolescent mothers in detail with regard to their pregnancy and childbirth. This qualitative study explores the experiences of adolescent mothers during pregnancy, childbirth, and care of their newborns.

METHODS

This qualitative study was based on data from focus group discussions and indepth interviews with teenage mothers in a suburb in Accra. Participants were recruited from health facilities as well as by snowball sampling.

RESULTS

Some of the participants became pregnant as a result of transactional sex in order to meet their basic needs, while others became pregnant as a result of sexual violence and exploitation. A few others wanted to become pregnant to command respect from people in society. In nearly all cases, parents and guardians of the adolescent mothers were upset in the initial stages when they heard the news of the pregnancy. One key finding, quite different from in other societies, was how often teenage pregnancies are eventually accepted, by both the young women and their families. Also observed was a rarity of willingness to resort to induced abortion.

CONCLUSION

Special programs should be initiated by the government and the various responsible departments to address ignorance on sexual matters, and the challenges and risks associated with pregnancy and parenting by adolescents. Parenting techniques should be taught in sex education programs.

Community perceptions of rape and child sexual abuse: a qualitative study in rural Tanzania

BACKGROUND

Rape of women and children is recognized as a health and human rights issue in Tanzania and internationally. Exploration of the prevailing perceptions in rural areas is needed in order to expand the understanding of sexual violence in the diversity of Tanzania's contexts. The aim of this study therefore was to explore and understand perceptions of rape of women and children at the community level in a rural district in Tanzania with the added objective of exploring those perceptions that may contribute to perpetuating and/or hindering the disclosure of rape incidences.

METHODS

A qualitative design was employed using focus group discussions with male and female community members including religious leaders, professionals, and other community members. The discussions centered on causes of rape, survivors of rape, help-seeking and reporting, and gathered suggestions on measures for improvement. Six focus group discussions (four of single gender and two of mixed gender) were conducted. The focus group discussions were recorded, transcribed verbatim, and analyzed using manifest qualitative content analysis.

RESULTS

The participants perceived rape of women and children to be a frequent and hidden phenomenon. A number of factors were singled out as contributing to rape, such as erosion of social norms, globalization, poverty, vulnerability of children, alcohol/drug abuse and poor parental care. Participants perceived the need for educating the community to raise their knowledge of sexual violence and its consequences, and their roles as preventive agents.

CONCLUSIONS

In this rural context, social norms reinforce sexual violence against women and children, and hinder them from seeking help from support services. Addressing the identified challenges may promote help-seeking behavior and improve care of survivors of sexual violence, while changes in social and cultural norms are needed for the prevention of sexual violence.

Physicians' reported needs of drug information at point of care in Sweden

AIMS

Relevant and easily accessible drug information at point-of-care is essential for physicians' decision making when prescribing. However, the information available by using Clinical Decision Support Systems (CDSSs) often does not meet physicians' requirements. The Summary of Product Characteristics (SmPC) is statutory information about drugs. However, the current structure, content and format of SmPCs make it difficult to incorporate them into CDSSs and link them to relevant patient information from the Electronic Health Records. The aim of the study was to evaluate the perceived needs for drug information among physicians in Sweden.

METHODS

We recruited three focus group discussions with 18 physicians covering different specialities. The information from the groups was combined with a questionnaire administered at the beginning of the group discussions.

RESULTS

Physicians reported their needs for knowledge databases at the point of drug prescribing. This included more consistent information about existing and new drugs. They also wished to receive automatically generated alerts for severe drug-drug interactions and adverse effects, and to have functions for calculating glomerular filtration rate to enable appropriate dose adjustments to be made for elderly patients and those with impaired renal function. Additionally, features enhancing electronic communication with colleagues and making drug information more searchable were suggested.

CONCLUSIONS

The results from the current study showed the need for knowledge databases which provide consistent information about new and existing drugs. Most of the required information from physicians appeared to be possible to transfer from current SmPCs to CDSSs. However, inconsistencies in the SmPC information have to be reduced to enhance their utility.

Physical Activity Among Adolescents in India: A Qualitative Study of Barriers and Enablers

Inadequate physical activity (PA) levels are reported in Indian youth, with lowest levels among adolescents, particularly girls. We aimed to identify barriers to and enablers of PA among school children in New Delhi and examine potential differences by gender and school type (government vs. private). A total of 174 students (private school students = 88, 47% girls; government school students = 86, 48% girls) aged 12 to 16 years from two Delhi schools participated in 16 focus group discussions (FGDs) conducted by bilingual moderators. We conducted FGDs separately for girls and boys, for students in Grades VIII and IX, and for private and government schools. We conducted FGDs among government school students in Hindi and translated the transcriptions to English for analysis. We coded transcriptions using a combination of inductive and deductive approaches, guided by the "youth physical activity promotion model." We identified various personal, social, and environmental barriers and enablers. Personal barriers: Private school girls cited body image-related negative consequences of PA participation. Social barriers: Girls from both schools faced more social censure for participating in PA. Environmental barriers: Reduced opportunity for PA in schools was commonly reported across all participants. Personal enablers: All participants reported perceived health benefits of PA. Social enablers: Several participants mentioned active parents and sports role models as motivators for increasing PA. Few environmental enablers were identified. This study highlights the need for further investment in physical activity within schools and for gender-sensitive policies for encouraging PA participation among adolescents in India.

Conceptions of Contraceptive Use in Rural KwaZulu-Natal, South Africa: Lessons for Programming

Community family planning programmes in South Africa arose from the controversial apartheid history of controlling the African population while encouraging the growth of European migrant population. Post-apartheid population policies shifted away from population control to aligning policies to the global agenda that placed emphasis on the link between population and development. The focus on population and development polices in post-apartheid South Africa is on social equality, justice and peace rather than controlling sections of the population. Given the shift, this paper interrogates the conceptions of contraceptive use among rural communities in KwaZulu-Natal. Our primary objective is to understand the dynamics surrounding access to and use of family planning services in peri-urban and rural areas of KwaZulu-Natal. Using focus group data, the findings of the study suggest that different social categories interact with the family planning programmes differently. How teenagers and married women perceive the value of family planning differs. Gender differences regarding the use of condoms are also evident. The paper attempts to grapple with the non-use of condoms despite the knowledge that these prevent pregnancy and provide protection from sexually-transmitted diseases. The contribution of this paper lies in its identification of socio-cultural factors and the political economy underlying the different attitudes towards contraceptive use in rural KwaZulu-Natal.

HIV-related risk perception among female sex workers in Nigeria

BACKGROUND

Over one-third of sex workers in Nigeria are infected with human immunodeficiency virus (HIV), yet there is a lack of understanding of sex workers' own perception of sexual risk-taking. Applying the theory of cognitive dissonance, this paper examined the personal HIV risk perception of brothel-based sex workers.

METHODS

The study is based on 24 focus group discussions held among brothel-based sex workers in four geographically and culturally dispersed cities in Nigeria.

RESULTS

It was found that sex workers underestimated their risk of infection and rationalized, defended, or justified their behaviors, a typical psychological response to worry, threat, and anxiety arising from the apparent discrepancies between beliefs and behaviors. To reduce dissonance, many sex workers had a strong belief in fatalism, predestination, and faith-based invulnerability to HIV infection. Many believed that one will not die of acquired immune deficiency syndrome if it is not ordained by God. The sex workers also had a high level of HIV-related stigma.

CONCLUSION

From these findings, most sex workers considered risk reduction and in particular condom use as far beyond their control or even unnecessary, as a result of their strong beliefs in fatalism and predestination. Therefore, one critical area of intervention is the need to assist sex workers to develop accurate means of assessing their personal vulnerability and self-appraisal of HIV-related risk.

Perception, Attitudes, and Experiences Regarding Mental Health Problems and Web Based Mental Health Information Amongst Young People with and without Migration Background in Germany. A Qualitative Study

Mental illnesses in adolescence and young adulthood are steadily increasing. Thus, mental disorders represent an individual and societal challenge and an enormous health economic burden, creating an urgent need for research and action. Mental health problems are omnipresent in the life of young people and the internet is the first resource, which helps them to understand their situation. Young people with migration background often have more difficulties accessing health care services. Digital technologies offer an ideal opportunity for a low-threshold platform that addresses the needs of young people. The current project "GeKo:mental" aims to design a multilingual website for Cologne-based adolescents and young adults that will enable them to obtain comprehensive information about mental illness and health, treatment options and first contact points. To design this website, this study aims to find out what kind of health information is needed and how it should best be presented. Nine focus group discussions with adolescents and young adults with and without migration background (N = 68) were conducted; the focus group discussions took place at schools, in an association for social youth work and in an cultural association, which is linked to a mosque in Cologne, Germany. A qualitative content analysis was conducted on the gathered material. The participants reported concrete challenges and needs. The results will form the basis for the development and design of a website.

"There Is Zero Regulation on the Selling of Alcohol": The Voice of the Youth on the Context and Determinants of Alcohol Drinking in Lebanon

Alcohol-related research from the Arab world has rarely touched on the experiences or views of Arab adolescents. In this article, we present an in-depth analysis of youth alcohol drinking patterns and determinants derived from focus group discussions completed with more than 100 Lebanese high school/vocational students (15-19 years). The social ecology of alcohol use framework guided our research and analysis. Findings reveal that alcohol drinking is perceived as a pervasive and serious public health problem, triggered by a complex web of social relations, and facilitated by lax policies. Recommendations to curb heavy/harmful alcohol drinking among adolescents include regulating the role of alcohol industry, providing alternative recreational spaces/pass-times, educating about alcohol-related harms, and promoting more research on alcohol and its harms. Findings confirm the social ecology of alcohol use framework, and suggest the addition of the macro level of influence to this model, namely, a comprehensive alcohol harm reduction policy.

General practitioners' perceptions of working with the certification of sickness absences following changes in the Swedish social security system: a qualitative focus-group study

BACKGROUND

Many physicians in Sweden, as well as in other countries, find the matter of certification of sickness absence (COSA) particularly burdensome. The issuing of COSAs has also been perceived as a work-environment problem among physicians. Among general practitioners (GPs) are the highest proportion of physicians in Sweden who experience difficulties with COSA. Swedish authorities have created several initiatives, by changing the social security system, to improve the rehabilitation of people who are ill and decrease the number of days of sick leave used. The aim of this study was to describe how GPs in Sweden perceive their work with COSA after these changes.

METHODS

A descriptive design with a qualitative, inductive focus-group discussion (FGD) approach was used.

RESULTS

Four categories emerged from the analysis of FGDs with GPs in Sweden: 1) Physicians' difficulties in their professional role; 2) Collaboration with other professionals facilitates the COSA; 3) Physicians' approach in relation to the patient; 4) An easier COSA process.

CONCLUSIONS

Swedish GPs still perceived COSA to be a burdensome task. However, system changes in recent years have facilitated work related to COSA. Cooperation with other professionals on COSA was perceived positively.

Workplace tobacco cessation program in India: A success story

CONTEXT

This paper describes the follow-up interventions and results of the work place tobacco cessation study.

AIMS

To assess the tobacco quit rates among employees, through self report history, and validate it with rapid urine cotinine test; compare post-intervention KAP regarding tobacco consumption with the pre-intervention responses and assess the tobacco consumption pattern among contract employees and provide assistance to encourage quitting.

SETTINGS AND DESIGN

This is a cohort study implemented in a chemical industry in rural Maharashtra, India.

MATERIALS AND METHODS

All employees (104) were interviewed and screened for oral neoplasia. Active intervention in the form of awareness lectures, focus group discussions and if needed, pharmacotherapy was offered. Medical staff from the industrial medical unit and from a local referral hospital was trained. Awareness programs were arranged for the family members and contract employees.

STATISTICAL ANALYSIS USED

Non-parametric statistical techniques and kappa.

RESULTS

Forty eight per cent employees consumed tobacco. The tobacco quit rates increased with each follow-up intervention session and reached 40% at the end of one year. There was 96% agreement between self report tobacco history and results of rapid urine cotinine test. The post-intervention KAP showed considerable improvement over the pre-intervention KAP. 56% of contract employees used tobacco and 55% among them had oral pre-cancerous lesions.

CONCLUSIONS

A positive atmosphere towards tobacco quitting and positive peer pressure assisting each other in tobacco cessation was remarkably noted on the entire industrial campus. A comprehensive model workplace tobacco cessation program has been established, which can be replicated elsewhere.

Motivational factors for participation in biomedical research: evidence from a qualitative study of biomedical research participation in Blantyre District, Malawi

Obtaining effective informed consent from research participants is a prerequisite to the conduct of an ethically sound research. Yet it is believed that obtaining quality informed consent is generally difficult in settings with low socioeconomic status. This is so because of the alleged undue inducements and therapeutic misconception among participants. However, there is a dearth of data on factors that motivate research participants to take part in research. Hence, this study was aimed at filling this gap in the Malawian context. We conducted 18 focus group discussions with community members in urban and rural communities of Blantyre in Malawi. Most participants reported that they accepted the invitation to participate in research because of better quality treatment during study also known as ancillary care, monetary and material incentives given to participants, and thorough medical diagnosis.

"You must first save her life": community perceptions towards induced abortion and post-abortion care in North and South Kivu, Democratic Republic of the Congo

Structural barriers such as a restrictive legal environment, limited medical resources, and high-costs inhibit access to safe abortion in the Democratic Republic of the Congo (DRC); these barriers are exacerbated by two decades of conflict. Socio-normative barriers further complicate access to safe abortion and post-abortion care (PAC) in DRC, where fear of abortion-related stigma may lead women to avoid PAC services. Programme partners support the Ministry of Health to provide good quality contraceptive and PAC services in North and South Kivu, DRC. This paper presents results from focus group discussions that explored community members' attitudes towards women who induce abortion and their care-seeking behaviour in programme areas. Results indicate that while abortion stigma was widespread, community members' attitudes towards women who induced abortions were not one-dimensional. Although they initially expressed negative opinions regarding women who induced abortion, beliefs became more nuanced as discussion shifted to the specific situations that could motivate a woman to do so. For example, many considered it understandable that a woman would induce abortion after rape: perhaps unsurprising, given the prevalence of conflict-related sexual violence in this area. While community members believed that fear of stigma or associated negative social consequences dissuaded women from seeking PAC, a majority believed that all women should have access to life-saving PAC. This commitment to ensuring that women who induced abortion have access to PAC, in addition to the professed acceptability of induced abortion in certain situations, indicates that there could be an opening to destigmatise abortion access in this context.

Reasons for delaying or engaging in early sexual initiation among adolescents in Nigeria

Background

Annually, over 1 million births in Nigeria are to teenage mothers. Many of these pregnancies are unwanted and these mothers are also exposed to the risk of human immunodeficiency virus (HIV) infection. Sexual abstinence is a critical preventative health strategy. Several quantitative studies in Nigeria have identified the correlates and determinants of early sex, yet few have explored in depth the underlying reasons for early sex. This paper explores both the key factors that motivate some unmarried young people to engage in early sex and reasons why some delay.

Methods

This qualitative study was based on data from 30 focus group discussions held with unmarried 14- to 19-year-olds in four geographically and culturally dispersed Nigerian states. Focus groups were stratified by sexual experience to capture variations among different subgroups.

Results

Several reasons for early premarital sex were identified. The “push” factors included situations where parents exposed young female adolescents to street trading. “Pull” factors, particularly for males, included the pervasive viewing of locally produced movies, peer pressure and, for females, transactional sex (where adolescent girls exchange sex for gifts, cash, or other favors). Also noted were overtly coercive factors, including rape. There were also myths and misconceptions that “justified” early sexual initiation. Reasons cited for delay included religious injunction against premarital sex; disease prevention (especially HIV/acquired immunodeficiency syndrome); fear of pregnancy, and linked to this, the fear of dropping out of school; and, for females, the fear of bringing shame to the family, which could lead to their inability to get a “good” husband in the future.

Conclusion

The differences observed between sexually active and abstinent adolescents were that the latter were more confident, had greater determination, and, most important, deployed refusal skills to delay first sex. Health promoters need to focus attention on educating adolescents in the skills needed to delay sexual debut.

'It's good enough': Swedish general dental practitioners on reasons for accepting substandard root filling quality

AIM

The concept of 'good enough' is central and necessary in the assessment of root filling quality. The aim was to explore the concept by analysing reasons and arguments for the acceptance or rejection of substandard root filling quality as reported by general dental practitioners (GDPs) in Sweden.

METHODOLOGY

The study was designed as a qualitative and exploratory study based on seven videotaped focus group interviews analysed by means of qualitative content analysis. Thirty-three GDPs employed in the Public Dental Health Service in Gothenburg, Sweden, participated (4-6 GDPs/interview). In all, nine predetermined questions were followed. Before each focus group, the participants received radiographs of 37 root fillings and were asked to assess the root filling quality. The three cases representing the most divergent assessments served as a basis for the discussion. The cases were presented without clinical information; the dentists would relate to the cases as being just root filled by themselves.

RESULTS

The radiographs did not provide a sufficient basis for decisions on whether or not to accept the root filling. This study emphasized that dentists did not primarily look for these arguments in the technical details of the root filling per se, but instead, they considered selected features of the contextual situation. The GDPs constantly introduced relevant 'ad hoc considerations' to account for the decisions they made. These contextual considerations were related to aspects of pulpal and periapical disease, risks (e.g. technical complications) or to consumed resources (personal and/or economic).

CONCLUSIONS

It was obvious that the concept of 'good enough' does not exist as a general formula ready to be applied in particular situations. Instead, it is necessarily and irremediably tied to contextual properties that emerge from case to case.

Public awareness of clinical trials: A qualitative pilot study in Pune

Context:

Medical expertise combined with availability of patients with varied diseases have resulted in rapid increase in number of clinical trials (CTs) recruiting millions of patients in India. Yet, few researchers have tried to understand if the public in India is aware of CTs.

Aims:

To explore the awareness, perceptions of and attitude towards participating in CTs among general public in Pune.

Materials and Methods:

Focus group discussions (FGDs) and interviews were conducted by contacting people in the community of various age groups and socio economic status with 7 Trial participants (TPs) and 17 Non Trial Participants (NTPs). The survey tool consisted of open-ended questions that assessed the awareness and attitudes of the individuals regarding the CTs. Interview were recorded on paper and translated from (Marathi) local language to English for analysis. Qualitative analysis was used to report the findings.

Results:

Most participants could associate CTs with medicine or development of new medicine; however they did not have a good understanding of the manner and safeguards with which CTs are conducted. Participants were not aware about different types of CTs and phases of the CTs. CTs were felt to be of benefit to the community and advancement of science. However, due to fear of adverse effects, 80% of the respondents were not ready to participate in the CTs.

Conclusions:

The Indian Pharmaceutical company is the world's 3^rd largest by volume as per Dr. Shivathanu Pillai's report 17th March 2010, in spite of that it has been noticed that the awareness about CTs is very low; therefore there is a need to create awareness about CTs which helps the participants to participate in CTs based on their own decision. These FGD findings require validation in a larger sample.

Establishing a model workplace tobacco cessation program in India

BACKGROUND

Tobacco use is highly prevalent and culturally accepted in rural Maharashtra, India.

AIMS

To study the knowledge, attitude, and practices (KAP) regarding tobacco consumption, identify reasons for initiation and continuation of tobacco use, identify prevalence of tobacco consumption and its relation with different precancerous lesions, provide professional help for quitting tobacco, and develop local manpower for tobacco cessation activities. SETTINGS, DESIGN, METHODS AND MATERIAL: The present study was conducted for one year in a chemical industrial unit in Ratnagiri district. All employees (104) were interviewed and screened for oral neoplasia. Their socio-demographic features, habits, awareness levels etc. were recorded. Active intervention in the form of awareness lectures, focus group discussions, one-to-one counseling and, if needed, pharmacotherapy was offered to the tobacco users.

RESULTS

All employees actively participated in the program. Overall, 48.08% of the employees were found to use tobacco, among which the smokeless forms were predominant. Peer pressure and pleasure were the main reasons for initiation of tobacco consumption, and the belief that, though injurious, it would not harm them, avoiding physical discomfort on quitting and relieving stress were important factors for continuation of the habit. Employees had poor knowledge regarding the ill-effects of tobacco. 40% of tobacco users had oral precancerous lesions, which were predominant in employees consuming smokeless forms of tobacco.

CONCLUSIONS

Identifying reasons for initiation and continuation of tobacco consumption along with baseline assessment of knowledge, attitudes, and practices regarding tobacco use, are important in formulating strategies for a comprehensive workplace tobacco cessation program.

Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change

BACKGROUND

In 2001, South Africa began implementing the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme. This programme included distribution of free formula milk for infants up to 6 months of age at all public health facilities. Effective from 1 January 2011, KwaZulu-Natal became the first province to phase out free formula milk from its PMTCT programme. On 23 August 2011, the South African National Department of Health adopted promotion of exclusive breastfeeding as the national infant feeding strategy and made a decision to withdraw free formula milk from the PMTCT programme.

OBJECTIVE

To explore the perceptions and understanding of households at community level on the policy decision to phase out free formula milk from the PMTCT programme in South Africa.

METHODS

An exploratory qualitative study was conducted amongst women enrolled in a community randomized trial known as Good Start III. Focus group discussions were held with grandmothers, fathers and teenage mothers; and in-depth interviews were performed with HIV-positive and HIV-negative mothers. Data were analysed using thematic analysis.

RESULTS

Identified themes included: (1) variations in awareness and lack of understanding of the basis for the policy change, (2) abuse of and dysfunctional policy as perceived reasons for policy change and (3) proposed strategies for communicating the policy change.

CONCLUSION

There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country.

"If you do not birget [manage] then you don't belong here": a qualitative focus group study on the cultural meanings of suicide among Indigenous Sámi in arctic Norway

Suicide is a major public health issue across the Arctic, especially among Indigenous Peoples. The aim of this study was to explore and describe cultural meanings of suicide among Sámi in Norway. Five open-ended focus group discussions (FGDs) were conducted with 22 Sámi (20) and non-Sámi (2) participants in South, Lule, Marka, coastal and North Sámi communities in Norway. FGDs were recorded, transcribed verbatim and analysed employing thematic analysis. Six themes were developed from the analysis: “Sámi are treated negatively by the majority society”, “Some Sámi face negative treatment from other Sámi”, “The historic losses of the Sámi have turned into a void”, “Sámi are not provided with equal mental health care”, “The strong Sámi networks have both positive and negative impacts” and “‘Birgetkultuvvra’ might be a problem”. The findings indicate that the participants understand suicide among Sámi in relation to increased problem load for Sámi (difficulties in life not encountered by non-Sámi) and inadequate problem-solving mechanisms on different levels, including lack of equal mental health care for Sámi and cultural values of managing by oneself (“ieš birget”). The findings are important when designing suicide prevention initiatives specifically targeting Sámi.

Patient and Provider Perspectives on a Decision Aid for Familial Hypercholesterolemia

Familial Hypercholesterolemia (FH) is an inherited disorder associated with increased cardiovascular risk that requires patients to make multiple impactful decisions regarding the management of their condition. Patient decision aids (PDAs) can facilitate shared decision-making (SDM) and enable patients to make choices that are concordant with their goals and values. To inform the development of a PDA for patients with FH, we employed a qualitative inductive approach and focus group discussions with patients, physicians, and genetic counselors. We explored and analyzed the perceptions and understanding of these stakeholders related to a PDA for FH and identified important concepts to include in the PDA. Categories emerging from focus group discussions included: (a) perceptions of a PDA related to FH; (b) discussion about the content of a PDA related to FH; and (c) SDM. In general, stakeholders were in favor of developing tools which can inform and individualize discussion about genetic testing and treatment options for FH. Physicians valued a tool that facilitates knowledge transfer to FH patients. Patients desired a tool to help them understand the genetic aspects of and treatment options related to FH. Genetic counselors emphasized the inclusion of visual aids to support discussion with patients. Potential barriers to and facilitators of PDA implementation were identified. The input of various stakeholders will inform the development of a prototype tool that will be iteratively tested before implementation in the clinical setting.

Listening to the consumer voice: developing multilingual cancer information resources for people affected by liver cancer

Background

In Australia, liver cancer incidence is rising, particularly among people born in hepatitis B‐endemic countries. We sought to build an understanding of the information needs of people affected by liver cancer, to inform the design of in‐language consumer information resources.

Methods

We searched the World Wide Web for available in‐language consumer information and conducted a literature search on consumers’ information needs and their preferred means of accessing it. Qualitative data collection involved bilingual researchers conducting focus group discussions (26 participants) and in‐depth interviews (22 participants) with people affected by liver cancer in English, Vietnamese, Cantonese and Mandarin. Sessions were audio‐recorded, transcribed, translated and thematically analysed. The key themes and salient findings informed the development of in‐language multimedia information resources.

Results

Many consumer resources did not cater for people with low literacy levels. The participants wanted more information on cancer diagnostic and treatment options, nutrition and Chinese Medicine and experienced communication challenges speaking to health professionals. While Vietnamese speakers relied entirely on information provided by their doctors, other participants actively searched for additional treatment information and commonly used the Internet to source it. We developed multilingual, multimedia consumer information resources addressing identified consumer information needs through an iterative process, in collaboration with our multilingual consumer panel. These resources are available in four languages, as separate modules accessible online and in DVD format.

Conclusion

This process enabled the development of user‐friendly patient resources, which complement health‐care provider information and supports informed patient decision making.

Urine diversion dry toilets in eThekwini Municipality, South Africa: acceptance, use and maintenance through users' eyes

This study was part of the VUNA project aimed to develop an affordable sanitation system that produces a valuable fertiliser, reduces pollution of water resources and promotes health. Urine diversion dry toilets (UDDTs) simplify the on-site hygienisation of faeces and allow for nutrient recovery from urine. Social acceptance is vital for the implementation of the UDDT, because sanitation is only effective if the system not only provides a well-designed toilet and effective waste management, but also offers users a facility that caters to their needs and is sensitive to their cultural lifestyle. This study used qualitative and quantitative methods to investigate acceptance, use and maintenance of UDDTs. Key findings indicate lower levels of acceptance of UDDTs among the elderly, who are accustomed to traditional pit toilets. The users aspire to own a flush toilet, perceived to be indicative of household wealth. A dominant concern was emptying the pit and the quality of the building material. Community interventions are required that will promote acceptance, understanding and encourage proper use and maintenance of the UDDT, and may need some technology modification. There is an urgent need for increased community participation to address users' perceptions, attitudes and behaviour concerning the UDDT.

Conducting caregiver focus groups on autism in the context of an international research collaboration: Logistical and methodological lessons learned in South Africa

LAY ABSTRACT

Most of the autism research to date has been conducted in high-income countries, with children and families typically from White, upper-middle-income backgrounds. However, we know there are significant inequalities that exist which influence how autistic individuals from diverse, underserved communities can access services they need. As many of these individuals have not been included in the majority of autism research to date, there is much we do not know about these individuals' life experiences, which are critically needed to better inform the development and implementation of care for families from historically underrepresented groups. In this article, we describe the research process we took to conduct focus group discussions with 22 caregivers of young autistic children living in Cape Town, South Africa. We specifically describe the lessons we learned in implementing these focus groups and provide recommendations aimed at how to best reduce logistical and methodological challenges moving forward to improve research conducted in similar low-resource contexts.