Consistency Between Administrative Health Records and Self-Reported Health Status and Health Care Use Among Indigenous Wayuu Health Insurance Enrollees: La Guajira, Colombia.

The objective of the study was to assess the consistency between self-reported demographic characteristics, health conditions, and healthcare use, and administrative healthcare records, in a sample of enrollees of an Indigenous health organization in Colombia. We conducted a phone survey of a random sample of 2113 enrollees September-2020/February-2021. Administrative health records were obtained for the sample. Using ICD-10 diagnostic codes, we identified individuals who had healthcare visits for diabetes, hypertension, and/or pregnancy. Using unique identifiers, we linked their survey data to the administrative dataset. Agreement percentages and Cohen's Kappa coefficients were calculated. Logistic regressions were performed for each health condition/state. Results showed high degree of agreement between data sources for sex and age, similar rates for diabetes and hypertension, 10% variation for pregnancy. Kappa statistics were in the moderate range. Age was significantly associated with agreement between data sources. Sex, language, and self-rated health were significant for diabetes. This is the first study with data from an Indigenous population assessing the consistency between self-reported data and administrative health records. Survey and administrative data produced similar results, suggesting that Anas Wauu can be confident in using their data for planning and research purposes, as part of the movement toward data sovereignty.

Characterising methamphetamine use to inform health and social policies in Manitoba, Canada: a protocol for a retrospective cohort study using linked administrative data.

INTRODUCTION: Rising use of methamphetamine is causing significant public health concern in Canada. The biological and behavioural effects of methamphetamine range from wakefulness, vigour and euphoria to adverse physical health outcomes like myocardial infarction, haemorrhagic stroke, arrhythmia and seizure. It can also cause severe psychological complications such as psychosis. National survey data point to increasing rates of methamphetamine use, as well as increasing ease of access and serious methamphetamine-related harms. There is an urgent need for evidence to address knowledge gaps, provide direction to harm reduction and treatment efforts and inform health and social policies for people using methamphetamine. This protocol describes a study that aims to address this need for evidence. METHODS: The study will use linked, whole population, de-identified administrative data from the Manitoba Population Research Data Repository. The cohort will include individuals in the city of Winnipeg, Manitoba, who came into contact with the health system for reasons related to methamphetamine use from 2013 to 2021 and a comparison group matched on age, sex and geography. We will describe the cohort's sociodemographic characteristics, calculate incidence and prevalence of mental disorders associated with methamphetamine use and examine rates of health and social service use. We will evaluate the use of olanzapine pharmacotherapy in reducing adverse emergency department outcomes. In partnership with Indigenous co-investigators, outcomes will be stratified by First Nations and Métis identity. ETHICS AND DISSEMINATION: The study was approved by the University of Manitoba Health Research Ethics Board, and access datasets have been granted by all data providers. We also received approval from the First Nations Health and Social Secretariat of Manitoba's Health Information Research Governance Committee and the Manitoba Métis Federation. Dissemination will be guided by an 'Evidence 2 Action' group of public rightsholders, service providers and knowledge users who will ensure that the analyses address the critical issues.

Mutual Pan-African support paradigm to produce scientific evidence of traditional medical practices for use against COVID-19 and emerging pandemics.

Africa is endowed with a profoundly rich and diverse system of plants and other bio-resources out of which, by traditional medicine practice, the people have satisfied their healthcare needs right from antiquity. In contemporary times, it has become necessary to modernize this traditional medical care system via scientific studies. Validation of the efficacy of health-enhancement products and drugs from plants and other bio-resources is predicated on diligent and intensive research accompanied by rigorous and conclusive clinical trials. Africa has eminently qualified human resources but due to the finance-intensive nature of medical research, individual African states on their own cannot fund the level of research desired for dealing with such serious issues as the COVID-19 pandemic. A collaboration among African states guided by a Mutual Pan-African support paradigm (MPASP) is a unique strategy for achieving success in any such a high-impact global project as the use of traditional medicine against COVID-19 and emerging pandemics; and this is hereby advocated.

The ripple effect: Examining the impact on parents of an Abecedarian early child care intervention in an urban social housing development.

The Abecedarian Approach is an internationally recognised early childhood intervention program that has shown long-term positive outcomes for children living in low SES communities. However, there are few studies examining the broader influence of such interventions for young children on the lives of their parents. This article describes the findings of a qualitative study exploring the perceptions and experiences of parents whose children attend an Abecedarian early intervention program located in an urban social housing complex. Eighteen parents whose children had attended the program for a minimum of one year were interviewed. The main themes that emerged were: strengthened relationships between parents and program staff, as well as between parents themselves, particularly supported through the home visitor; increased awareness among parents about early development and of their role in supporting child development; and opportunities for parents' personal growth. The findings suggest that high quality early child intervention programs, such as the Abecedarian Approach, can positively impact the lives of parents.

Housing Conditions Linked to Tick (Ixodida: Ixodidae) Infestation in Rural Areas of Colombia: A Potential Risk for Rickettsial Transmission.

This cross-sectional study explores the different conditions related to the infestation of ticks in households and the potential risks for rickettsial transmission in Urabá, Colombia. The main outcome of interest was villagers' perception of tick infestation. The data were analyzed using a clog-log mixed regression model. Ticks were collected from infested humans to diagnose infection by spotted fever group rickettsiae (SFGR). In addition, a thematic analysis of qualitative data from key informants concerning knowledge about ticks was conducted. The prevalence of infestation of ticks in households was estimated at 60.99% (95% CI: 51.58-93.51). The multivariate model suggested that households with palm leaf roofs (PR = 1.95; 95% CI: 1.19-2.95), canines (PR = 1.76; 95% CI: 1.21-2.46), rats (PR = 2.19; 95% CI: 1.45-3.08), and with the presence of opossums in areas surrounding the households (PR = 1.51; 95% CI: 1.05-2.10) had a higher prevalence of tick infestation. Two samples of the tick species Amblyomma patinoi were found infected with Rickettsia amblyommatis and Candidatus Rickettsia colombianensi. A thematic analysis provided the names that local community members give to ticks, areas where ticks are common, and the individuals at risk of infestation. The presence of domestic, synanthropic, and wild animals suggests a high risk of the dissemination of ticks inside dwellings and close to them in these rural areas.

Early life exposure to antibiotics and the risk of mood and anxiety disorders in children and adolescents: A population-based cohort study.

OBJECTIVE: Mood and anxiety disorders (MADs) are common conditions with multiple aetiologies. Exposure to antibiotics has been proposed as a possible risk factor in animal studies. We aimed to assess maternal antibiotic use in pregnancy and child antibiotic use in the first three years of life, collectively called early life, as potential risk factors for subsequent development of MADs during childhood and adolescence. METHODS: A population-based retrospective cohort study was conducted including 221,139 children born in Manitoba, Canada between 1996 and 2012. Exposure was defined as having filled one or more antibiotic prescriptions during early life. Children were followed until the earliest MADs diagnoses, 19th birthday, migration, death, or end of the study period. We computed crude and adjusted hazard ratios (aHRs) with corresponding 95% confidence intervals (CIs) using Cox proportional hazard regression. RESULTS: Children born to mothers who received one or more antibiotic courses in pregnancy had significantly higher rates of MADs compared with non-exposed children (aHR 1.08, 95% CI 1.03,1.13). Overall antibiotic exposure during the first three years of life was not significantly associated with MADs (aHR 1.00, 95% CI 0.94,1.07). A significantly increased risk of MADs was observed after postnatal exposure to tetracyclines, aminoglycosides, quinolones (33%) or sulfonamides and trimethoprim (28%). Postnatal exposure to macrolides, lincosamides, and streptogramins significantly reduced the risk of MADs by 16%. CONCLUSION: Early life exposure to antibiotics is associated with different risk effects on MADs in children. The apparent associations may have been confounded by indication and may not be clinically meaningful.

Indigenous Men Adhering to Highly Active Antiretroviral Therapy: Navigating Through Culturally Unsafe Spaces While Caring for Their Health.

Introduction: Indigenous peoples in Canada have endured and continue to experience the impact of colonization by European settlers. The deleterious manifestations of intergenerational historic trauma (HT) are evidenced in the high HIV/AIDS epidemic-related premature mortality rates among Indigenous men, despite the availability of novel highly active antiretroviral therapies (HAARTs). Aim: The aims of this study were to explore the impact of historic trauma (HT) on treatment adherence and health promoting practices among Indigenous men living with HIV, and how resilience was both expressed and mediated by survivor status. Methods: This interpretive description study incorporated a cultural safety lens. Through partnership with the Vancouver Native Health Society, 36 male HT survivors were recruited using purposive and theoretical sampling. They told their lived experiences and health promoting practices with respect to HAART adherence through interviews and a focus group. Results: Two broad categories (findings) emerged: (1) resilience as facilitator of HAART adherence; and (2) differential views on HT's impact. Resilience was expressed through nine concepts. Conclusion: Most Indigenous men in this study demonstrate health promoting behavior, stay on HAART and have better health and well-being even if the environments they live in are marginalized or heavily stigmatizing. This study shows that areas of strength and adaptation, including factors promoting resilience can be harnessed to foster HAART adherence. With a consideration of these areas of strength and adaptation, this study offers implications for research and recommendations to improve treatment-adherent behavior, fostering healing from HT, and reducing HIV/AIDS-related deaths.

An Evaluation of an Experiential Learning Program in Global and Indigenous Health: The University of Manitoba's Queen Elizabeth II Diamond Jubilee Scholarship Program.

We conducted a mixed-methods outcome evaluation to examine student experiences and learning in the University of Manitoba's Queen Elizabeth II Diamond Jubilee Scholarship Program in Global and Indigenous Health. Our scholarship program is a bi-directional, 3-month international experiential learning program, including both undergraduate and graduate students, with associated online course focused on community engagement. Students completed a semi-structured narrative report at the conclusion of their funding related to their experience and learning. The Likert questions were analyzed descriptively and student responses to the open-ended questions were utilized for thematic analysis. Also included in this paper is a summary of our lessons learned through program administration. A total of 38 students completed the program between 2016 and 2018, with 95% reporting that they either met or exceeded their goals in the program. Three overarching and inter-related themes emerged in our thematic-analysis of students' narrative reports, including success through relationships and new perspectives, challenges of the unfamiliar, and personal growth through strong emotions. Many students reported personal growth as their greatest success and linked this with new perspectives and awareness of how different contexts shaped their understanding of health issues. Overcoming challenges in their placements contributed to students' confidence in their ability to problem-solve. Overall, students reported value in their experiential learning, which further supports the growing trend to incorporate both experiential learning and formal education in community engagement in public health pedagogy. However, international experiential learning requires considerable financial and human resource commitments to ensure its success.

Conceptualizations of help-seeking for mental health concerns in First Nations communities in Canada: A comparison of fit with the Andersen Behavioral Model.

This qualitative study explored the fit between on-reserve First Nations community members' conceptualizations of help-seeking for mental health concerns and the Andersen Behavioral Model of Health Services Use. Youth, adults and elders (N = 115) living and or working in eight distinct First Nations communities within a tribal council area in Canada participated in focus groups or individual interviews that were transcribed, coded and then analyzed using a thematic analysis approach informed by grounded theory methodology. Resulting themes were then mapped onto the Andersen Behavioral Model of Health Services Use. Participants' conceptualizations of predisposing characteristics including social structures, health beliefs and mental illness, enabling and impeding resources had a high degree of fit with the model. While perspectives on perceived need for mental health care, and spirituality as a health and lifestyle practice had only moderate fit with the model, these domains could be modified to fit First Nations' interpretations of help-seeking. Participants' perceptions of avoidant strategies and non-use of mental health services, however did not map onto the model. These findings suggest conceptualizations of help-seeking for mental health issues in these First Nations communities are only partially characterized by the Andersen Behavioral Model, suggesting there are a number of considerations to Indigenize the model. Findings also highlight potential explanations for why some members of this population may not access or receive appropriate mental health treatment. Multi-pronged efforts are warranted to link culturally normed pathways of help-seeking with effective mental health supports for First Nations community members in Canada.

Predictors of Women's Satisfaction with Prenatal Care in a Canadian Setting.

OBJECTIVE: Prenatal care is a vital and important part of a healthy pregnancy, providing many maternal and health benefits. Despite Canada's publically funded health care system with universal access, inadequate rates of prenatal care continue to be observed. As a modifiable risk factor, the process variables that influence satisfaction with prenatal care in Canadian settings have received little attention. The objective of this study was to identify the predictors of satisfaction with prenatal care. METHODS: A cross-sectional, descriptive, correlational design was used to examine the relationships between expectations, interpersonal processes of care, the quality of prenatal care, personal characteristics, and the type of provider with overall satisfaction, and with four dimensions of satisfaction. A convenience sample of 216 pregnant women was surveyed using self-administered questionnaires with women in their third trimester. Multiple linear regression analyses were used to identify predictors of satisfaction. RESULTS: The quality of prenatal care and provider interpersonal style together explained 80% of the variance in overall satisfaction. Patient-centered decision-making was a significant predictor of satisfaction with information, while having a midwife was a predictor of satisfaction with system characteristics. Expectations were not related to satisfaction. CONCLUSIONS FOR PRACTICE: Improving quality of care, provider interpersonal style and patient-centered decision making, and improving the structural characteristics of prenatal care may be effective in improving women's satisfaction and utilization of prenatal care.

Maternal Social and Economic Factors and Infant Morbidity, Mortality, and Congenital Anomaly: Are There Associations?

Experiences during infancy create durable and heritable patterns of social deprivation and illness producing health disparities. This retrospective cohort study of 71 836 infants from Winnipeg, Manitoba, assessed associations between maternal social and economic factors and infant mortality, morbidity, and congenital anomaly. This study found that newborn and postneonatal hospital readmissions are inversely associated with geography. Additionally, social context, including maternal history of child abuse, is associated with infant postneonatal hospital readmissions. Geography and education are associated with infant mortality. Income was not associated with infant mortality or morbidity following adjustment for social support. Interestingly, congenital anomaly rates are 1.2 times more common among 2 parent families and male infants. Understanding associations between infant health and maternal social and economic factors may contribute to interventions and policies to improve health equity.

Sociocultural descriptions of febrile syndromes in rural areas of Urabá, Colombia: An exploration of "tick fever" / Descrição sociocultural de síndromes febris em áreas rurais de Antioquia Urabá: um olhar sobre a "febre do carrapato"

Abstract Introduction: In 2006 and 2008 there were two lethal outbreaks of rickettsioses in the rural areas of Urabá, characterized by the lack of immediate diagnosis and antibiotic treatment. Objective: Describe sociocultural aspects about knowledge, attitudes and practices in relation to febrile syndromes and "tick fever" in rural areas of Urabá. Materials and methods: We conducted an exploratory study using knowledge, attitudes, and practices questionnaires and semi-structured interviews about febrile syndromes and "tick fever". We surveyed 246 heads of households and interviewed nine individuals. Results: We observed that people tended to identify febrile syndromes with signs and clinical symptoms of dengue, malaria, leptospirosis and rickettsioses. A considerable proportion of individuals (32.93%) knew very little about "tick fever", thinking that is was transmitted by mosquitos. They mentioned intestinal parasitoids, malaria, dengue, and "evil eye" among the causes of febrile syndromes. "Tick fever" is linked by its name to the bite of the tick. Furthermore, the treatments for febrile syndromes mentioned by interviewees are associated to those commonly used in western medicine and medicinal plants. Conclusions: There is a need for educational programs in rural areas, to raise awareness about these potential lethal conditions that can be effectively treated.

Resumo Introdução: Nos anos de 2006 e 2008, dois surtos letais de riquetsiose foram relatados em áreas rurais de Urabá, caracterizados pela falta de atenção imediata para o diagnóstico e tratamento com antibióticos. Objetivo: Descrever aspectos socioculturais do conhecimento, atitudes e práticas de síndromes febris e "febre do carrapato" em áreas rurais de Antioquia, Urabá. Materiais e métodos: Realizou-se estudo exploratório, através de inquéritos sobre CAP (conhecimentos, atitudes e práticas) e entrevistas semiestruturadas sobre síndromes febris e "febre do carrapato", um nome que se refere às doenças das riquetsioses na área. Foram aplicados 246 inquéritos sobre a CAP foram realizadas aos chefes de agregados familiares e nove pessoas foram entrevistadas. Resultados: Observou-se que as pessoas tendem a identificar os sinais e sintomas clínicos característicos da dengue, malária, leptospirose e até riquetsiose. Um grande número de pessoas demonstra baixo conhecimento sobre "febre do carrapato" e indicou que ela é transmitida por mosquitos (32,93%). Os entrevistados indicaram que as causas das diferentes síndromes febris se devem a parasitas intestinais, malária, dengue ou, como crença cultural, ao "mau olhado". A "febre do carrapato" o associa, pelo nome, com a mordida do carrapato. Além disso, o tratamento das síndromes febris referidas pelos entrevistados está intimamente relacionado ao uso comum da medicina ocidental e ao uso de "plantas medicinais". Conclusões. É necessário ter programas de educação nessas áreas rurais para que essas entidades potencialmente letais tenham um tratamento efetivo e acessível.

Participatory action as a research method with public health nurses.

AIM: This article explores and describes participatory action research (PAR) as a preferred method in addressing nursing practice issues. This is the first study that used PAR with public health nurses (PHNs) in Canada to develop a professional practice model. BACKGROUND: Participatory action research is a sub-category of action research that incorporates feminist and critical theory with foundations in the field of social psychology. For nurses, critical analysis of long-established beliefs and practices through PAR contributes to emancipatory knowledge regarding the impact of traditional hierarchies on their practice. DESIGN: This study used participatory action, a non-traditional but systematic research method, which assisted participants to develop a solution to a long-standing organizational issue. METHOD: The stages of generating concerns, participatory action, acting on concerns, reflection and evaluation were implemented from 2012 - 2013 in an urban Canadian city, to develop a professional practice model for PHNs. FINDINGS: Four sub-themes specific to PAR are discussed. These are "participatory action research engaged PHNs in development of a professional practice model;" "the participatory action research cycles of "Look, Think, Act" expanded participants' views;" "participatory action research increased awareness of organizational barriers;" and "participatory action research promoted individual empowerment and system transformation." CONCLUSIONS: This study resulted in individual and system change that may not have been possible without the use of PAR. The focus was engagement of participants and recognition of their lived experience, which facilitated PHNs' empowerment, leadership and consciousness-raising.

What Goes Around: the process of building a community-based harm reduction research project.

BACKGROUND: Often, research takes place on underserved populations rather than with underserved populations. This approach can further isolate and stigmatize groups that are already made marginalized. What Goes Around is a community-based research project that was led by community members themselves (Peers). CASE PRESENTATION: This research aimed to implement a community-based research methodology grounded in the leadership and growing research capacity of community researchers and to investigate a topic which community members identified as important and meaningful. Chosen by community members, this project explored how safer sex and safer drug use information is shared informally among Peers. Seventeen community members actively engaged as both community researchers and research participants throughout all facets of the project: inception, implementation, analysis, and dissemination of results. Effective collaboration between community researchers, a community organization, and academics facilitated a research process in which community members actively guided the project from beginning to end. CONCLUSIONS: The methods used in What Goes Around demonstrated that it is not only possible, but advantageous, to draw from community members' involvement and direction in all stages of a community-based research project. This is particularly important when working with a historically underserved population. Purposeful and regular communication among collaborators, ongoing capacity building, and a commitment to respect the experience and expertise of community members were essential to the project's success. This project demonstrated that community members are highly invested in both informally sharing information about safer sex and safer drug use and taking leadership roles in directing research that prioritizes harm reduction in their communities.

"People try and label me as someone I'm not": The social ecology of Indigenous people living with HIV, stigma, and discrimination in Manitoba, Canada.

Indigenous peoples (First Nations, Inuit, and Métis) are currently overrepresented in the HIV epidemic in Canada and are infected at a younger age than those who are not Indigenous. This article presents our findings on the stigma and discrimination (as well as related themes such as disclosure) experienced by Indigenous people who contracted HIV in their youth and live in urban and non-urban settings in Manitoba, Canada. The findings were derived from a qualitative study that sought to understand the experiences and needs of Indigenous people living with HIV (including AIDS). We situate such experiences within a social ecological framework towards developing a better structural understanding of the impacts of stigma and discrimination on the lives of Indigenous people who are HIV positive. Stigma and discrimination caused barriers for Indigenous people living with HIV through inhibiting their ease of access to supports including family, peers, community, and long- and short-term health services. Creative forms of outreach and education that are culturally appropriate and/or rooted in culture were considered to be possibly impactful ways of reducing stigma and discrimination at the community level. Learning from communities who are successfully managing stigma also showed promise for developing new programming.

Reorienting Public Health Nurses' Practice With a Professional Practice Model.

Purpose Documents articulating public health nurses' (PHNs') roles, including Canadian standards and competencies, depict a broad focus working at multiple levels to improve population outcomes through the promotion of health equity. Conversely, Canadian experts depict a looming crisis, based on the rising disconnect between daily activities and ideal practice. While perfectly positioned, PHNs' skills and abilities are under-utilized and largely invisible. The intention of this study was to develop a model to support the full scope of equity-focused PHN practice. Method A participatory action research approach was used. Qualitative data were gathered using semistructured interview guides during audio-recorded meetings. The data were coded into central themes using content analysis and constant comparison. A researcher reflexive journal and field notes were kept. A significant feature was full participant involvement. Results The outcome was a professional practice model to reframe the PHN role to focus on population health and equity. The model was imperative in promoting full scope of practice, dealing with workload pressures, and describing PHNs' value within the organization and broader health system. Conclusion Professional practice models hold promise as frameworks to depict autonomous practice activities, situated within organizations and healthcare systems, and underpinned by nursing knowledge.

A qualitative study on the intersectional social determinants for indigenous people who become infected with HIV in their youth.

BACKGROUND: Indigenous young people are currently highly overrepresented in the HIV epidemic in Canada, especially in the Prairie Provinces, such as Manitoba. Understanding HIV-vulnerability in Indigenous peoples must begin with understanding that social determinants are intersectional and linked to the historical legacy of European colonization. In this paper findings that detail the influence of the intersectional social determinants on Indigenous people who become infected with HIV in their youth are presented. METHODS: The qualitative research design of phenomenology was used as it afforded the opportunity to understand Indigenous young people from their frames of reference and experiences of reality, resulting in a phenomenological understanding of their perspectives and experiences of the early years of living with HIV. A total of 21 Indigenous young people took part open-ended interviews. RESULTS: The stories that the Indigenous young people shared revealed their deeply interconnected social worlds, and how social determinants including abuse, trauma, being part of the child welfare system, and housing and food security were connected throughout various stages of their lives. Such stages included childhood, adolescence and young adulthood (the time of HIV infection), and later adulthood for older participants with the social determinants having multiple influences on their health trajectories. CONCLUSIONS: The findings highlight the need for policies and programs that are broadly focused, addressing multiple social determinants together. Overall, there needs to be more emphasis on the multiple social determinants in the life situations of all Indigenous youth. Reducing the health and social disparities in Indigenous youth is key to reducing the number of young Indigenous people diagnosed with HIV. The findings also shed light on the importance of listening to young Indigenous people who have experienced HIV diagnosis and life following diagnosis.

Guías bilingües: una estrategia para disminuir las barreras culturales en el acceso y la atención en salud de las comunidades wayuu de Maicao, Colombia / Bilingual guides: a strategy to decrease cultural barriers to health care access in the Wayuu communities of Maicao, Colombia

RESUMEN Este artículo estudia la función del guía bilingüe como actor en la disminución de la brecha en el acceso y la atención en salud de las comunidades indígenas wayuu de Colombia. En el marco de un proyecto de VIH llevado a cabo entre los años 2012 y 2014, se realizaron 24 entrevistas a actores claves del área administrativa y de salud, incluyendo guías bilingües wayuu. A partir del análisis cualitativo se identificaron tres barreras culturales respecto al acceso a la atención en salud: a) idioma; b) cosmovisión wayuu sobre el cuerpo, la salud y la enfermedad; c) información sobre salud sexual y reproductiva y VIH culturalmente no adaptada. El estudio identifica al guía bilingüe como actor clave en la disminución de estas barreras y finaliza con una discusión sobre el rol de los guías, las tensiones inherentes a su labor, y la complejidad de su aporte como mediadores culturales.

ABSTRACT The article examines the use of bilingual guides to decrease cultural barriers to health care access in the Wayuu indigenous communities of Colombia. Within a larger project on HIV carried out between 2012 and 2014, 24 interviews were conducted with key actors in the administrative and health areas, including Wayuu bilingual guides. As a result of the qualitative analysis, the study identified three cultural barriers to health care access: a) language; b) the Wayuu worldview regarding the body, health, and illness; and c) information about sexual and reproductive health and HIV not adapted to the Wayuu culture. The study identifies the bilingual guides as key actors in reducing these barriers and concludes with a discussion of the role of the guides, the tensions inherent to their work, and the complexity of their contributions as cultural mediators.

Choosing an out-of-hospital birth centre: Exploring women's decision-making experiences.

OBJECTIVE: the primary objective for this study was to explore women's experiences of choosing to plan a birth at an out-of-hospital birth centre. We sought to understand how women make the choice to plan for an out-of-hospital birth and the meaning that women ascribe to this decision-making process. DESIGN, SETTING, AND PARTICIPANTS: a qualitative phenomenological study was conducted in Winnipeg, Canada with a sample of seventeen post partum women who represent the socio-demographic characteristics of the actual users of the Birth Centre in Winnipeg. The women participated in semistructured interviews. Through a feminist perspective and using interpretative phenomenological analysis (IPA), each participant's experience of birthplace decision-making was explored. FINDINGS: six themes emerged through the analysis: (1) Making the decision in the context of relationships; (2) Exercising personal agency; (3) An expression of one's ideology; (4) Really thinking it through; (5) Fitting into the eligibility criteria; and (6) The psychology of the space. The findings suggested that a woman's sense of safety was related to each of these themes. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the birth centre decision-making experience has many similarities to the homebirth decision-making process. The visceral impact of the physical design of the facility plays an important role and differentiates the birth centre decision from other birth setting options. The concept of relational autonomy was emphasised in this study, in that women make the decision in the context of their relationships with their midwives and partners. The study has implications for midwifery practice and health-care policy related to: client education on birth settings, design of birth environments, validation of the birth centre concept, and upholding the women-centred midwifery model of care. The study highlighted the importance of increasing access to out-of-hospital birth centres.

Barriers and facilitators related to implementation of regulated midwifery in Manitoba: a case study.

BACKGROUND: In 2000, midwifery was regulated in the Canadian Province of Manitoba. Since the establishment of the midwifery program, little formal research has analyzed the utilization of regulated midwifery services. In Manitoba, the demand for midwifery services has exceeded the number of midwives in practice. The specific objective of this study was to explore factors influencing the implementation and utilization of regulated midwifery services in Manitoba. METHODS: The case study design incorporated qualitative exploratory descriptive methods, using data derived from two sources: interviews and public documents. Twenty-four key informants were purposefully selected to participate in semi-structured in-depth interviews. All documents analyzed were in the public domain. Content analysis was employed to analyze the documents and transcripts of the interviews. RESULTS: The results of the study were informed by the Behavioral Model of Health Services Use. Three main topic areas were explored: facilitators, barriers, and future strategies and recommendations. The most common themes arising under facilitators were funding of midwifery services and strategies to integrate the profession. Power and conflict, and lack of a productive education program emerged as the most prominent themes under barriers. Finally, future strategies for sustaining the midwifery profession focused on ensuring avenues for registration and education, improving management strategies and accountability frameworks within the employment model, enhancing the work environment, and evaluating both the practice and employment models. Results of the document analysis supported the themes arising from the interviews. CONCLUSION: These findings on factors that influenced the implementation and integration of midwifery in Manitoba may provide useful information to key stakeholders in Manitoba, as well as other provinces as they work toward successful implementation of regulated midwifery practice. Funding for new positions and programs was consistently noted as a successful strategy. While barriers such as structures of power within Regional Health Authorities and inter and intra-professional conflict were identified, the lack of a productive midwifery education program emerged as the most prominent barrier. This new knowledge highlights issues that impact the ongoing growth and capacity of the midwifery profession and suggests directions for ensuring its sustainability.