Accessibility of web-based health information for women in midlife from culturally and linguistically diverse backgrounds or with low health literacy.

OBJECTIVE: To measure the accessibility of Australian web-based health information for midlife women including those from culturally and linguistically diverse (CALD) backgrounds or with low health literacy. METHODS: Search terms relating to midlife health were entered into Google Australia to identify health information websites. The content of the first two results pages was assessed using the European Commission's quality criteria for health websites. Readability was assessed using the Flesch Readability Ease Score with Grade 8 accepted as the average Australian reading level. RESULTS: Sixteen websites were evaluated. Accessibility scores ranged between 0 and 8. The Victorian Government's health website Better Health Channel and the Jean Hailes for Women's Health website contained the most accessible information, each scoring 8, but were both 'difficult to read' on the readability test. Four websites included written resources in languages other than English and two had information in audio-visual format in languages other than English. CONCLUSIONS: There is a gap in accessible online health information for Australian women from CALD backgrounds or those with low health literacy. IMPLICATIONS FOR PUBLIC HEALTH: Healthy behaviour changes in midlife may lead to better health in older age. More accessible health information resources are needed for women in midlife from CALD backgrounds and those with low health literacy.

Gestational diabetes mellitus: a qualitative study of lived experiences of South Asian immigrant women and perspectives of their health care providers in Melbourne, Australia.

BACKGROUND: South Asian women are at a high risk of developing gestational diabetes mellitus than other women in Australia. Gestational diabetes affects up to 14-19% of all pregnancies among South Asian, South East Asian, and Arabic populations placing women at risk of adverse pregnancy outcomes. Although, gestational diabetes resolves after childbirth, women with gestational diabetes are up to seven times more likely to develop type 2 diabetes within five to ten years of the index pregnancy. Increasingly, South Asian women are being diagnosed with gestational diabetes in Australia. Therefore, we aimed to gain a better understanding of the lived experiences of South Asian women and their experiences of self-management and their health care providers' perspectives of treatment strategies. METHODS: Using an ethnographic qualitative research methodology, semi-structured one-on-one, face-to-face interviews were conducted with 21 health care providers involved in gestational diabetes management and treatment from the three largest tertiary level maternity hospitals in Melbourne, Victoria, Australia. In-depth interviews were conducted with 23 South Asian women post diagnosis between 24-28 weeks gestation in pregnancy. RESULTS: Health care providers had challenges in providing care to South Asian women. The main challenge was to get women to self-manage their blood glucose levels with lifestyle modification. Whilst, women felt self-management information provided were inadequate and inappropriate to their needs. Women felt 'losing control over their pregnancy', because of being preoccupied with diet and exercise to control their blood glucose level. CONCLUSIONS: The gestational diabetes clinical practice at the study hospitals were unable to meet consumer expectations. Health care providers need to be familiar of diverse patient cultures, rather than applying the current 'one size fits all' approach that failed to engage and meet the needs of immigrant and ethnic women. Future enabling strategies should aim to co-design and develop low Glycaemic Index diet plans of staple South Asian foods and lifestyle modification messages.

An evaluation of dietary intakes of a selected group of South Asian migrant women with gestational diabetes mellitus.

Background: Women of South Asian descent have an increased risk of developing gestational diabetes mellitus (GDM), and type 2 diabetes mellitus compared to Caucasian women. Dietary advice provided by health practitioners to this group has been found to be culturally inappropriate. The aim of this study was to describe the dietary intakes of South Asian women with gestational diabetes and use this information to develop culturally appropriate dietary models for education and support of dietary management.Method: An in-depth diet and lifestyle survey was administered with 13 eligible women. Dietary histories were collected for pre-pregnancy, during pregnancy and post-GDM diagnosis to evaluate changes in dietary intake, diet and health beliefs and traditional foods consumed during pregnancy.Results: The diets of participants did not meet nutrient requirements for pregnancy; specific areas on concern were dietary fibre, calcium, iron, folate and iodine. Vegetarians were particularly at risk with regards to energy and protein intake. Generally dietary intakes of these women with GDM were not consistent with guidelines for management of GDM. Confusion about what they should eat for GDM, health practitioner advice and conflict with cultural expectations about foods to consume during pregnancy was evident.Conclusion: The dietary information collected from these women was used to model sample menus for GDM that were culturally appropriate and consistent with vegetarian and non-vegetarian eating patterns.

Breastfeeding practices of ethnic Indian immigrant women in Melbourne, Australia.

BACKGROUND: The health benefits of breastfeeding are well documented in public health and medical literature worldwide. Despite this, global rates of breastfeeding steadily decline during the first couple of months postpartum. Although immigrant women have higher initiation rates and a longer duration of breastfeeding overall, breastfeeding practices are compromised because of a myriad of socioeconomic and cultural factors, including the acculturation process. The objective of this study was to show how acculturation and cultural identity influenced breastfeeding practices among Indian immigrants in Melbourne, Australia. METHODS: Twelve case studies were employed to gather narratives of women's lived experiences. Ethnographic field research methods were used to collect data, including participant observation, semi-structured interviews, case studies, and life histories. This provided in-depth information from women on various aspects of the immigrant experience of motherhood, including infant care and feeding. Participants were opportunistically recruited from Indian obstetricians and gynaecologists. Women identifying as ethnic Indian and in their third trimester of pregnancy were recruited. Interviews were conducted in women's homes in metropolitan Melbourne over a 12 month period between 2004 and 2005. Data were coded and analysed thematically. RESULTS: All women identified as ethnic Indian and initiated breastfeeding in accordance with their cultural identity. Social support and cultural connectivity impacted positively on duration of breastfeeding. However, acculturation (adopting Australian cultural values and gender norms, including returning to paid employment) negatively influenced breastfeeding duration. In addition, the high reliance of recent immigrants on the advice of healthcare professionals who gave inconsistent advice negatively affected exclusive breastfeeding. CONCLUSIONS: For ethnic Indian immigrant women breastfeeding practice is closely linked to acculturation and identity construction, both personal and communal. The lack of social and cultural networks for recent immigrants prevents their involvement in the cultural systems that traditionally support breastfeeding. With this in mind, healthcare professionals should deliver services in a culturally appropriate and sensitive manner where women feel supported as well as empowered.

Tackling complexities in understanding the social determinants of health: the contribution of ethnographic research.

OBJECTIVE: The complexities inherent in understanding the social determinants of health are often not well-served by quantitative approaches. My aim is to show that well-designed and well-conducted ethnographic studies have an important contribution to make in this regard. Ethnographic research designs are a difficult but rigorous approach to research questions that require us to understand the complexity of people's social and cultural lives. APPROACH: I draw on an ethnographic study to describe the complexities of studying maternal health in a rural area in India. I then show how the lessons learnt in that setting and context can be applied to studies done in very different settings. RESULTS: I show how ethnographic research depends for rigour on a theoretical framework for sample selection; why immersion in the community under study, and rapport building with research participants, is important to ensure rich and meaningful data; and how flexible approaches to data collection lead to the gradual emergence of an analysis based on intense cross-referencing with community views and thus a conclusion that explains the similarities and differences observed. CONCLUSION: When using ethnographic research design it can be difficult to specify in advance the exact details of the study design. Researchers can encounter issues in the field that require them to change what they planned on doing. In rigorous ethnographic studies, the researcher in the field is the research instrument and needs to be well trained in the method. IMPLICATION: Ethnographic research is challenging, but nevertheless provides a rewarding way of researching complex health problems that require an understanding of the social and cultural determinants of health.

International migration and gestational diabetes mellitus: a systematic review of the literature and meta-analysis.

Influxes of migrant women of childbearing age to receiving countries have made their perinatal health status a key priority for many governments. The international research collaboration Reproductive Outcomes And Migration (ROAM) reviewed published studies to assess whether migrants in countries of resettlement have a greater risk of gestational diabetes mellitus (GDM) than women in receiving countries. A systematic review of the literature from Medline, Embase, PsychInfo and CINAHL from 1990 to 2009 included studies of migrant women and GDM. Studies were excluded if there was no cross-border movement or comparison group or if the receiving country was not the country of resettlement. Studies were assessed for quality, analysed descriptively and meta-analysed. Twenty-four reports (representing >120,000 migrants) met our inclusion criteria. Migrants were described primarily by geographic origin; other relevant aspects (e.g. time in country, language fluency) were rarely studied. Migrants' results for GDM were worse than those for receiving-country women in 79% of all studies. Meta-analyses showed that, compared with receiving-country women, Caribbean, African, European and Northern European women were at greater risk of GDM, while North Africans and North Americans had risks similar to receiving-country women. Although results of the 31 comparisons of Asians, East Africans or non-Australian Oceanians were too heterogeneous to provide a single GDM risk estimate for migrant women, only one comparison was below the receiving-country comparison group, all others presented a higher risk estimate. The majority of women migrants to resettlement countries are at greater risk for GDM than women resident in receiving countries. Research using clear, specific migrant definitions, adjusting for relevant risk factors and including other aspects of migration experiences is needed to confirm and understand these findings.

Lived experience of gestational diabetes mellitus among immigrant South Asian women in Australia.

BACKGROUND: Women from South Asia have a high incidence of gestational diabetes mellitus (GDM) placing them at risk of adverse pregnancy outcomes. Despite the higher rates of GDM in this group, there are no studies of their experiences of living with GDM in Australia or elsewhere. AIMS: We aimed to explore the experiences and understandings of South Asian women in Melbourne, Australia, after diagnosis with GDM. METHODS: A qualitative approach was used. Face-to-face in-depth interviews were conducted with 17 immigrant women from South Asia recently diagnosed with GDM. They were interviewed in the language of their choice at two time points: in pregnancy after GDM diagnosis and at six weeks postpartum. Thematic analysis was conducted to identify common patterns and salient themes within and across narratives, also taking into account any divergent experiences. RESULTS: Before the diagnosis of GDM, women's knowledge and awareness of any diabetes were low. Women and their partners were upset by the diagnosis. Dietary advice received was seen to be challenging in the context of culturally different food habits and consequently managing diet after diagnosis proved difficult. Different attitudes to exercise in pregnancy also raised issues for women. Women said they would try their best to maintain lifestyle modifications postnatally, but were uncertain about sustaining these in the long term. CONCLUSION: South Asian women require culturally appropriate advice regarding strategies to reduce their risk of GDM as early as possible in pregnancy, ideally at the time pregnancy is confirmed.

Life with a new baby: how do immigrant and Australian-born women's experiences compare?

OBJECTIVE: Little is known about immigrant mothers' experiences of life with a new baby, apart from studies on maternal depression. Our objective was to compare the post-childbirth experiences of Australian-born and immigrant mothers from non-English speaking countries. METHODS: A postal survey of recent mothers at six months postpartum in Victoria (August 2000 to February 2002), enabled comparison of experiences of life with a new baby for two groups of immigrant women: those born overseas in non-English-speaking countries who reported speaking English very well (n=460); and those born overseas in non-English-speaking countries who reported speaking English less than very well (n=184) and Australian-born women (n=9,796). RESULTS: Immigrant women were more likely than Australian-born women to be breastfeeding at six months and were equally confident in caring for their baby and talking to health providers. No differences were found in anxiety or relationship problems with partners. However, compared with Australian-born women, immigrant mothers less proficient in English did have a higher prevalence of depression (28.8% vs 15%) and were more likely to report wanting more practical (65.2% vs 55.4%) and emotional (65.2% vs 44.1%) support. They were more likely to have no 'time out' from baby care (47% vs 28%) and to report feeling lonely and isolated (39% vs 17%). CONCLUSION AND IMPLICATIONS: Immigrant mothers less proficient in English appear to face significant additional challenges post-childbirth. Greater awareness of these challenges may help to improve the responsiveness of health and support services for women after birth.

Public and/or private health care: tuberculosis patients' perspectives in Myanmar.

BACKGROUND: Tuberculosis is a major public health problem in Myanmar as in other developing countries. About 73% of TB patients seek care at private general practitioners' clinics before presenting to the public TB centre, raising questions about how best to prevent transmission and maintain treatment regimens. METHOD: The study was conducted in two townships in Yangon Division in Myanmar in 2004, and examined treatment seeking behaviour of TB patients and their views towards public and private health care services. This was an exploratory descriptive study. Both quantitative and qualitative research methods were employed in data collection from TB patients, health care professionals, and members of various agencies involved in TB Control Programme. RESULTS: A considerable delay was found between the onset of symptoms of TB and seeking treatment (five days - two months). General practitioners were the first point of contact in all cases. Old TB patients influenced the treatment seeking behaviour and choice of treatment clinics of new TB patients. Most patients viewed the public health sector as a place to obtain free treatment and the private sector as a fee-paying, convenient and better place to seek treatment. CONCLUSION: The involvement of private general practitioners is crucial for effective TB control in Myanmar. The selection of GPs for partnership with the public sector is vital to the success of public-private partnership in controlling TB.

Perils and possibilities: achieving best evidence from focus groups in public health research.

OBJECTIVE: Focus group research is often seen as a cost-effective way of gathering evidence from multiple research participants about the diversity of their views, experiences or beliefs. Our objective is to argue that focus group research only fulfils its potential if analysis of individual views is extended to include analysis of interaction between participants, so that we learn more why people hold these views. APPROACH: We outline the literature on focus group research, contrasting the 'quick-and-easy' approach with the demands of studies that are designed, conducted and analysed in a methodologically rigorous way to yield high quality public health evidence. CONCLUSION: Well-conducted focus groups contribute good evidence for public health decision making. The challenges of conducting high-quality studies should not be underestimated, and must involve rigorous analysis of both interaction and content.

Impact of ritual pollution on lactation and breastfeeding practices in rural West Bengal, India.

BACKGROUND: Breastfeeding in India is universal and prolonged. Several cultural practices are associated with lactation and breastfeeding in India, mainly revolving around the concept of ritual purity and 'hot and cold' foods, food avoidance, restricted diet after childbirth, and remaining in seclusion for a certain time period because of the polluting effects of childbirth. This study on breastfeeding practices explored how the concept of ritual pollution influenced practices after delivery, including during lactation and breastfeeding. METHODS: The study was conducted in four villages of West Bengal State in India, representing different levels of socioeconomic development, religion, and caste/tribe from September 1993 to April 1994. One hundred households with one woman respondent from each household were selected from each village. Both qualitative and quantitative methods were employed for data collection. A survey questionnaire was administered to 402 respondents and in-depth interviews were conducted with 30 women in the reproductive age group (13-49 years), and 12 case studies were documented with women belonging to different caste, religious, and tribal groups. RESULTS: Belief in 'impurity and polluting effects of childbirth' necessitated seclusion and confinement of mothers after childbirth in the study villages. Breastfeeding was universal and prolonged, and food proscriptions were followed by mothers after childbirth to protect the health of their newborn. Initiation of breastfeeding was delayed after birth because of the belief that mother's milk is 'not ready' until two-to-three days postpartum. Generally, colostrum was discarded before putting the infant to the breast in the study villages. Breastfeeding lasted up to five years, and the majority of women in the sample introduced supplementary food before six months. Most infants in the study villages were given a prelacteal feed immediately after birth, only a small number of women (35) exclusively breastfed - after giving a prelacteal feed - until six months in the study villages. CONCLUSION: Cultural and traditional practices have considerable implications on lactation and breastfeeding, and in the overall well-being and health of mothers and infants. Breastfeeding programs should take into account traditional beliefs and concepts when communicating with families about practices such as food restriction and food avoidance.

Ethical review and the assessment of research proposals using qualitative research methods.

The role of Human Research Ethics Committees (HRECs) in health research is well established. Ethics committees have the good of research participants in mind but they must also assess scientific merit including the design and conduct of studies. In this article the authors' focus is on qualitative research method and the challenge that the National Statement on Ethical Conduct in Human Research (2007) poses for ethics committees when they assess proposals using the methods outlined in the National Statement. We set out a process for judging the standard of qualitative research proposals and propose that qualitative health research can be assessed using a hierarchy designed for evaluating interview studies. We contrast well-designed studies with those that have design flaws in order to focus on the hallmarks of research merit in studies that use qualitative research methods. Finally, we show that our proposal is compatible with the National Statement. Ethics review provides an early opportunity to identify and redesign inadequate studies that will not contribute to our knowledge base. The challenge for members of ethics committees with little experience in qualitative studies is to be able to assess research excellence by assessing research merit in proposals, recognising the special design features of qualitative research methods.

Women's perspectives of pain following day surgery in Australia.

OBJECTIVE: To investigate the incidence of pain following discharge from reproductive day surgery. DESIGN: Cross-sectional descriptive study. SETTING: A public hospital for women in Melbourne. SUBJECTS: 315 women participated in phone interviews and 10 in face-to-face interviews. MAIN OUTCOME MEASURE(S): Self-reports of pain were assessed in relation to age, English and non-English speaking background, prior experience of day surgery, type of surgery, time in recovery, information provision prior to surgery, and access to significant others at home. RESULTS: Older women were less likely to report having pain immediately following discharge (regression coefficient = -0.72, 95% CI, 0.58 to 0.88, p < or = 0.01), or within 48 hours following discharge (regression coefficient = - 0.71, 95% CI, 0.57 to 0.88, p < or = 0.05). Women with a prior experience of day surgery were 1.9 times more likely to be in pain within 48 hours following surgery (regression co-efficient 1.88, 95% CI, 1.134 to 3.10, p < or = 0.05). Women who understood information were less likely to report that they experienced pain within 48 hours of discharge (regression co-efficient -0.74, 95% CI, 0.24 - 0.95, p < or = 0.05). CONCLUSIONS: Younger patients, those who have had prior experience of day surgery and those who received inadequate information prior to surgery were most likely to report pain. Adequate individual patient assessment will ensure that patients' experience of pain following day surgery is minimised.

Missing girls and son preference in rural India: looking beyond popular myth.

Survival chances of girls in parts of South and East Asia have been adverse. Female foeticide, infanticide, abandonment, out-adoption, under-reporting of female births, and selective neglect of girls leading to higher death rates, have contributed to this adversity. Here, I reflect on an observed skewed sex ratio at birth in rural West Bengal, and discuss female foeticide, infanticide, son preference, and abortion. More boys were recorded at birth, and the majority of women desired sons. Trajectories of selective neglect of and discrimination against daughters have been researched extensively, but the related issues of female foeticide and infanticide have been less examined.

Gynaecological day surgery and quality of care.

The aim of the study was to explore the experiences of Australian public and private patients undergoing gynaecological day surgery in a public hospital. A telephone survey was conducted with 315 women within two days of hospital discharge. The findings indicate that patients generally favour the "in and out" experience of day surgery, with some reservations. Prior to hospital admission, private patients were less likely to have access to multiple sources of information as well as information that they found easy to understand. Alternative means of supporting women recovering from day surgery may be needed for those whose family members and/or friends cannot provide sufficient support following discharge. This study contributes to discussion on setting objective standards to evaluate the health system in the field of day surgery.