Perceptions of long-term impact and change following a midwife-led biomass smoke education program for mothers in rural Uganda: a qualitative study.

INTRODUCTION: Women and children in Uganda and other low- and middle-income countries are exposed to disproportionately high levels of household air pollution from biomass smoke generated by smoke-producing cookstoves, especially in rural areas. This population is therefore particularly vulnerable to the negative health effects caused by household air pollution, including negative pregnancy outcomes and other health issues throughout life. The Midwife Project, a collaboration between research and health teams in the UK and Uganda, began in 2016 to implement an education program on lung health for mothers in Uganda, to reduce the health risks to women and children. Education materials were produced to guide midwives in the delivery of health messages across four rural health centres, and mixed-methods results of knowledge questionnaires and interviews demonstrated knowledge acquisition, acceptability and feasibility. This qualitative follow-up study aimed to improve understanding of the longer term impact of this education program from the perspective of midwives, village health team members and mothers, in consideration of rolling the program out more widely in rural Uganda. METHODS: Purposive sampling was carried out to recruit consenting antenatal or postnatal women, midwives and village health team members who had been involved in an education session. Individual interviews were conducted with 12 mothers and four village health team members, and four focus groups were conducted with 10 midwives in total. Interviews and focus groups were conducted across all four health centres by two researchers and six translators as appropriate depending on language spoken (English or Lusoga). These were semi-structured and directed by topic guides. Reflective and observational notes were also made. A thematic analysis was carried out by two researchers, along with production of a narrative for each mother, to enrich understanding of each individual story. RESULTS: Midwives and village health teams had continued with the program well past the project end date and all mothers expressed making, or intending to make, changes, suggesting long-term feasibility and acceptability. Main themes generated were ability to change and changes made, ability to change dictated by money, importance of practical education, perceived health improvements, and passing on knowledge. Additional findings were that some education topics seemed to be overlooked, and there was a lack of clarity about the village health team role for the purposes of this program. Some mothers had been motivated to overcome financial barriers, for example by reconstructing cooking areas cheaply themselves. However, information given in the program about building advice and potential financial gains was inconsistent. CONCLUSION: Recommendations for future biomass smoke education should include explicit building advice, emphasis on financial gains, encouragement to share the knowledge acquired and clarification of the village health team role. These program changes will improve focus and relevancy, optimise impact and, with behaviour change and implementation strategy in mind, could be used for widespread rollout in rural Uganda. Future research should include quantitative data collection to objectively examine surprising perceived health benefits, including reduction in malaria and burns, and further qualitative work on why some education content appears neglected.

What is the evidence documenting the effects of marine or coastal nature conservation or natural resource management activities on human well-being in South East Asia? A systematic map.

BACKGROUND: Conservation activities and natural resource management interventions have often aimed to tackle the dual challenge of improving nature conservation and human well-being. However, there is concern over the extent to which this dual goal has been achieved, and an increasing recognition of trade-offs and synergies within and between aspects of each of the goals. The amount and scope of the available evidence on the success of conservation and management interventions in both arenas has lacked documentation, for a number of reasons, including limited resources for monitoring and evaluation and the difficulty in bringing together a disparate evidence base. This systematic map focuses on the interaction between marine conservation management and the health and well-being of coastal communities in South East Asia. METHOD: We searched bibliographic databases to find published literature, and identified grey literature through institutional and organisational website searches and key stakeholders. Eligibility criteria were applied in two stages, title and abstract and full text, with consistency checks. We extracted meta-data on the design and characteristics of each study, from which we produced an interactive database and map, and a narrative summary. RESULTS: We assessed 42,894 records at title and abstract from the main searches. 1,331 articles were assessed at full text (30 articles were not retrievable). 287 articles (281 studies) were included in the systematic map. Most studies were peer-reviewed publications (90%), and from the Philippines and Indonesia (72%). 31% of studies were solely qualitative, 45% were solely quantitative and 24% included both qualitative and quantitative research. Only 24% (31/127) of quantitative studies included a comparator. We identified knowledge clusters where studies investigated the links between the marine conservation interventions: Site Protection, Economic or Livelihood Incentives or Alternatives, or Habitat Management, and the human health and well-being outcomes: Economic Living Standards, Governance and Empowerment, or Social Relations. In addition, qualitative research clusters were identified exploring the links between the intervention Habitat Management, and the outcome Governance and Empowerment, and between the intervention Economic or Livelihood Incentives or Alternatives, and the outcomes of Governance and Empowerment, and Social Relations. We identified major knowledge gaps in evidence for the effect of marine conservation interventions on the outcomes Freedom of Choice and Action, Security and Safety, Subjective Well-being, Health, and Culture and Spirituality. There was a lack of studies involving Education, Awareness and Activism interventions that reported any human health and well-being outcomes. CONCLUSION: We present the first updatable, interrogable and comprehensive evidence map on this topic for South East Asia. Our work supports further, detailed investigation of knowledge clusters using systematic review and also serves to identify understudied topic areas. The lack of comparative, quantitative studies suggests that future research should include counterfactuals to strengthen the robustness of evidence base. Users of this systematic map should recognise that much evidence may be national or locally specific, and that we did not undertake an assessment of study quality. Thus, when considering implications for policy and decision-making, users should carefully consider the heterogeneity of available evidence and refer to original research articles to gain a full depth of understanding and context.

'Digital Dancing' - "Can you see, what I feel" - An exploration of the physical 'experience' of dance for Parkinson's through 3-dimensional motion analysis.

BACKGROUND: Parkinson's is a common, progressive, neurodegenerative movement disorder of the central nervous system. Research has consistently shown that dancing can have a positive impact on the lives of people living with Parkinson's (PwP). PwP who dance report that current measurement of the effects fails to appreciate the multifactorial presentation of the condition as well as the biopsychosocial potential of dance holistically. AIM: To explore the feasibility of combining measurements of whole-body movement using 3-dimensional motion analysis with the lived experience of dance for PwP, to see if it is possible to 'see (measure)' what PwP say they 'feel (experience)' when dancing, in a 'mind/body approach' METHOD: : Thirteen PwP and ten Carers took part in three community delivered 'Parkinson's Dance Science' classes followed by focus group reflection. Three PwP wore a 3-dimensional, motion capture suit that recorded whole-body movement throughout the class and were interviewed about their experiences. Data were analysed using a 'Convergent Parallel' mixed methods design, mapping participant's experiences and reflections over six biomechanical movement variables. RESULTS: Quantitative results indicate that it is possible to use 3-dimensional motion capture to measure biomechanical change during and following dance in PwP but the amount and direction of change was different for each participant. Qualitative results showed PwP felt the methods were feasible and reported a positive immediate and long-term effect of dance in a complete 'mind/body experience'. The sample size did not permit further analysis, but areas of development suggest it may not be the change in physical ability that is important, but more the perception of change following dance that is unique to each individual. Thus single measures of the effects of dance for PwP are likely to be insufficient when trying to understand the effect holistically. CONCLUSION: A 'Convergent Parallel' mixed methods research design, mapping the experience of dance for PwP ('what I feel') and their peers against biomechanical change ('what you see') following dance is feasible. Further research is required to develop the method with a larger sample to truly begin to understand the potential and effects of dance for PwP.

Community physiotherapy for people with dementia following hip fracture: Fact or fiction? A qualitative study.

BACKGROUND: Physiotherapy is a core component of rehabilitation following a hip fracture. Approximately 40% of people sustaining a hip fracture will have dementia, but there is little evidence to guide physiotherapy interventions in this population. OBJECTIVE: This study forms part of a process evaluation seeking to explore reasons why people with dementia were not referred for physiotherapy following a hip fracture and challenges that are faced treating these people in the community. METHODS: We undertook a series of structured focus groups and interviews with physiotherapists based in community-rehabilitation services in the South West of England. Qualitative data sought to explain reasons why people with dementia were not being referred for onward physiotherapy following discharge from the acute setting after hip fracture. Framework analysis was used to make sense of the data. RESULTS: Four focus groups and interviews were undertaken with physiotherapists and assistants working in community settings. Three main themes were determined - beliefs, the importance of pathways of care and the effect of resources on decision making. DISCUSSION: Out data suggest that people with dementia were often labelled as having 'no rehabilitation potential' in the acute setting and this excluded them from receiving ongoing therapy in the community setting. It was also suggested that physiotherapists were judging this potential using biomedical measures of outcome which fails to recognise the importance of person centred care for this population. CONCLUSION: There was suggestion of therapeutic nihilism when considering rehabilitation for this population, whereby it is assumed that people with dementia cannot be rehabilitated, so they are not given the opportunity. It is unsurprising that outcomes for this population are poor considering the reluctance to provide physiotherapy to people with dementia following hip fracture.

Intervention development and treatment success in UK health technology assessment funded trials of physical rehabilitation: a mixed methods analysis.

OBJECTIVES: Physical rehabilitation is a complex process, and trials of rehabilitation interventions are increasing in number but often report null results. This study aimed to establish treatment success rates in physical rehabilitation trials funded by the National Institute of Health Research Health Technology Assessment (NIHR HTA) programme and examine any relationship between treatment success and the quality of intervention development work undertaken. DESIGN: This is a mixed methods study. SETTING: This study was conducted in the UK. METHODS: The NIHR HTA portfolio was searched for all completed definitive randomised controlled trials of physical rehabilitation interventions from inception to July 2016. Treatment success was categorised according to criteria developed by Djulbegovic and colleagues. Detailed textual data regarding any intervention development work were extracted from trial reports and supporting publications and informed the development of quality ratings. Mixed methods integrative analysis was undertaken to explore the relationship between quantitative and qualitative data using joint displays. RESULTS: Fifteen trials were included in the review. Five reported a definitive finding, four of which were in favour of the 'new' intervention. Eight trials reported a true negative (no difference) outcome. Integrative analysis indicated those with lower quality intervention development work were less likely to report treatment success. CONCLUSIONS: Despite much effort and funding, most physical rehabilitation trials report equivocal findings. Greater focus on high quality intervention development may reduce the likelihood of a null result in the definitive trial, alongside high quality trial methods and conduct.

A scoping review comparing two common surgical approaches to the hip for hemiarthroplasty.

BACKGROUND: Hemiarthroplasty for hip fracture is a common surgical procedure. A number of distinct approaches are used to access the hip joint. The most commonly used are the direct lateral approach (DLA), and the posterior approach (PA). Internationally there is little consensus on which of these approaches to use. Current guidance is based on a limited selection of evidence and choice of approach is frequently based on surgeon preference. Historically, recommendations have been made based on dislocation rates. In light of technical advancements and greater recognition of patient priorities, outcomes such as post-operative function and pain may be considered more important in the modern context. The aim of this scoping review was to summarise the literature pertaining to the comparison of common surgical approaches to the hip for hemiarthroplasty. METHODS: A scoping review methodology was used to examine the range and nature of primary research. Using systematic methods we searched for studies that directly compared the DLA and PA. Studies reporting the following outcomes were considered; dislocation, mortality, pain, activities of daily living, functionality, health-related quality of life, length of stay, surgeon assessment of difficulty, and adverse events. MEDLINE, EMBASE and The Cochrane Library were searched. Relevant information was extracted and synthesis of the retrieved data followed a basic content analytical approach. RESULTS: A total of 13 studies were retrieved: 12 observational studies and 1 randomised trial. The majority of studies were based at single sites. Larger observational studies using multi-site and national registry data have emerged in recent years. Reporting of technique and outcomes is inconsistent. A trend for higher rates of dislocation using the PA was observed and eight studies recommended the use of the DLA over the PA. CONCLUSIONS: This scoping review demonstrates that the existing evidence is highly heterogeneous in nature and not of a sufficient quality to inform practice recommendations. This issue would be best addressed by additional RCTs, and high quality national-level observational data. Standardisation of the recording of patient risk factors, surgical and post-operative intervention protocols, and outcomes in all study designs would strengthen the potential for valid comparison of future findings.

Research excellence across clinical healthcare: a novel research capacity building programme for nurses and midwives in a large Irish region.

Background: A lack of support and research skills development has contributed to low research output by clinically based nurses and midwives in Ireland, including those in specialised and advanced roles. A novel research capacity building (RCB) programme was developed to address existing barriers. The programme was developed and implemented using Cooke's principles of RCB. Nurses and midwives participated from acute hospital, community, public health, mental health, older adult, intellectual disability, addiction and palliative care settings. Aims: This paper provides an evaluation of the Research Excellence Across Clinical Healthcare (REACH) programme from 2013-2016. Methods: Document analysis was used to evaluate RCB activities and outputs. Data were extracted from programme reports, conference proceedings, paper references, and workshop and conference sign-in/evaluation forms. Results: Individuals (n = 17) and small research groups (n = 4) were supported. Increased research capacity was demonstrated through dissemination of research in peer-reviewed journals, posters and oral presentations at national and international conferences. Sustainability was demonstrated by progression of participants to PhD (n = 3) and research projects that remain ongoing (n = 5). Skills development was facilitated by the organisation of workshops and conferences. Conclusions: A programme that provides academic support and mentorship in the clinical environment along with skills development can build research capacity. Future research should involve follow-up to determine any long-term effects.

Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU).

BACKGROUND: Health literacy concerns the capacities of people to meet the complex demands of health in modern society. In spite of the growing attention for the concept among European health policymakers, researchers and practitioners, information about the status of health literacy in Europe remains scarce. This article presents selected findings from the first European comparative survey on health literacy in populations. M ETHODS: The European health literacy survey (HLS-EU) was conducted in eight countries: Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland and Spain (n = 1000 per country, n = 8000 total sample). Data collection was based on Eurobarometer standards and the implementation of the HLS-EU-Q (questionnaire) in computer-assisted or paper-assisted personal interviews. R ESULTS: The HLS-EU-Q constructed four levels of health literacy: insufficient, problematic, sufficient and excellent. At least 1 in 10 (12%) respondents showed insufficient health literacy and almost 1 in 2 (47%) had limited (insufficient or problematic) health literacy. However, the distribution of levels differed substantially across countries (29-62%). Subgroups within the population, defined by financial deprivation, low social status, low education or old age, had higher proportions of people with limited health literacy, suggesting the presence of a social gradient which was also confirmed by raw bivariate correlations and a multivariate linear regression model. DISCUSSION: Limited health literacy represents an important challenge for health policies and practices across Europe, but to a different degree for different countries. The social gradient in health literacy must be taken into account when developing public health strategies to improve health equity in Europe.

Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q).

BACKGROUND: Several measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations. METHODS: Based on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish. RESULTS: The development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors. CONCLUSIONS: By illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.

Health literacy and public health: a systematic review and integration of definitions and models.

BACKGROUND: Health literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy. METHODS: A systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model. RESULTS: The review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively. CONCLUSIONS: Based upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.