'I might have cried in the changing room, but I still went to work'. Maternity staff balancing roles, responsibilities, and emotions of work and home during COVID-19: An appreciative inquiry.

PROBLEM: Knowing how to help staff thrive and remain in practice in maternity services. BACKGROUND: A chronic shortage of staff in maternity services in the United Kingdom and high levels of stress and burnout in midwifery and medical staff. PURPOSE: To understand how to support and enhance the wellbeing of staff in a small UK maternity service. METHODS: An appreciative inquiry using interviews with n = 39 maternity staff and n = 4 group discussions exploring meaningful experiences, values and factors that helped their wellbeing. RESULTS: Staff members were highly motivated, managing a complex melee of emotions and responsibilities including challenges to professional confidence, mental health, family situation, and conflict between work-life roles. Despite staff shortages, a demanding workload, professional and personal turmoil, and the pandemic participants still found meaning in their work and relationships. DISCUSSION: A 'whole person' approach provided insight into the multiple stressors and emotional demands staff faced. It also revealed staff resourcefulness in managing their professional and personal roles. They invested in relationships with women but were also aware of their limits - the need to be self-caring, employ strategies to switch-off, set boundaries or keep a protective distance. CONCLUSION: Staff wellbeing initiatives, and research into wellbeing, would benefit from adopting a holistic approach that incorporates home and family with work. Research on emotion regulation strategies could provide insights into managing roles, responsibilities, and the emotional demands of working in maternity services. Emotion regulation strategies could be included in midwifery and obstetric training.

Virtual reality used to distract children and young people with long-term conditions from pain or pruritus: A scoping review using PAGER.

AIMS AND OBJECTIVES: To map out the primary research studies relating to how virtual reality (VR) has been used to distract children and young people with long-term conditions from pain or pruritus. BACKGROUND: Pharmacologic treatment of chronic pain and pruritus may have side effects; hence, non-invasive non-pharmacological treatments are being sought. DESIGN: The scoping review followed the methodology recommended by the Joanna Briggs Institute, PAGER framework and PRISMA-ScR checklist. The protocol was registered with the Open Science Registration on 14 February 2022 https//doi.org/10.17605/OSF.IO/K2R93. METHODS: Five databases (Medline, CINAHL, PsycINFO, Web of Science and Scopus) were searched. Data were extracted from primary research studies published between 2000 and 2022 involving children and adolescent populations (<21 years) with a long-term condition that had an element of enduring pruritus and/or pain. RESULTS: Of 464 abstracts screened, 35 full-text papers were assessed with 5 studies meeting the eligibility criteria. Three main themes emerged from the included studies: (1) Improvements in pain and daily functioning; (2) positive perceptions of VR and (3) accessibility and feasibility of VR. No papers were found on the effect of VR on alleviating pruritus. CONCLUSION: VR is feasible, acceptable, and safe for children and adolescents with chronic pain in a range of long-term conditions and offers promise as an adjunctive treatment for improving chronic pain and quality of life. No studies were identified that targeted pruritis or measured pruritis outcomes; thus, the effects of VR for pruritis are unknown. There is a need for rigorously designed, randomised controlled trials to test the clinical and cost-effectiveness of VR interventions for chronic pain and pruritis in children and adolescents. The use of the PAGER (Patterns, Advances, Gaps, Evidence for Practice and Research Recommendations) framework for scoping reviews helped to structure analysis and findings and identify research gaps. RELEVANCE TO CLINICAL PRACTICE: VR interventions offer promise in improving chronic pain related to long-term conditions.

Perceptions around COVID-19 and vaccine hesitancy: A qualitative study in Kaski district, Western Nepal.

Burgeoning morbidity and mortality due to COVID-19 pandemic including the peaks in outbreaks due to different variants have attracted global attention. Although the development and rolling out of vaccines have been impressive, low- and middle-income countries suffer from a double burden: (1) lack of adequate vaccines; and (2) low vaccine uptake (vaccine hesitancy). The main objective of this study was to explore perceptions around COVID-19 and vaccine hesitancy among urban and rural population in Western Nepal. A qualitative study was conducted in six urban wards of Pokhara municipality and four rural municipalities in Kaski district of Nepal. A semi-structured interview guide was used to interview participants who were selected purposively to explore the perceived burden of COVID-19 pandemic, roles, and contributions of vaccine. Nineteen interviews were conducted by telephone following a government recommendation to avoid face-to-face meetings. Audio-recorded interviews were thematically analysed after transcription and translation into English. COVID-19 is a major (public) health concern and affects people at an individual, societal and national level. People dreaded its health hazards and consequences and seemed to be compliant with public health measures such as maintaining social distance, wearing masks and maintaining hygiene. Vaccine was considered to be a major intervention to fight the pandemic, nonetheless, the rationale and benefits of vaccines were blemished by the perceived lack of the vaccine's effectiveness, duration of protection, and its potential side-events. Expedited development of vaccine was embraced with suspicion that vaccine may have incurred compromise in quality. Science and rationale behind vaccine were smeared by misinformation and clearly counteracting the misinformation were deemed critical. Providing information about vaccines through government entities (who are trusted) and respected individuals may engender trust and uptake of vaccine. Fighting off misinformation of COVID-19 is critical to curb the course of pandemic. Increased attention towards monitoring and investing in legitimacy of information and offering information through trusted sources can help improve the vaccine coverage.

Why use Appreciative Inquiry? Lessons learned during COVID-19 in a UK maternity service.

Choosing the 'right' research method is always an important decision. It affects the type of study questions that can be answered. In addition, the research method will have an impact on the participants - how much of their time it takes, whether the questions seem important to them and whether there is any benefit in taking part. This is especially important when conducting research with staff in health services. This article is a reflection on the process of using Appreciative Inquiry (AI) in a study that explored staff wellbeing in a UK maternity unit. We share our key learnings to help others decide if AI will fit their research aims, as well as highlight issues in its design and conduct. We discuss our experience of using AI,the strengths and limitations of this approach, and conclude with points to consider if you are thinking about using AI. Although a study team was actively involved in decisions, this paper is largely based on reflections by the first author, the researcher conducting the field work in the maternity services.

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal.

INTRODUCTION: Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings. METHODS: This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys. RESULTS: The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014). CONCLUSION: BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.

Factors associated with contraceptive use in rural Nepal: Gender and decision-making.

INTRODUCTION: Gender norms and roles influence many decisions related to reproductive health behaviours including contraceptive use. There are very few studies related to gender norms and decision-making in contraceptive use in Nepal, hence this paper addresses these issues in a quantitative study. METHODS: A secondary data analysis of a primary study conducted in 2012 as a quantitative cross-sectional study in four villages of a hilly district in Nepal. This study included data that were collected from either the woman or the man in 440 couples of childbearing age with at least one child. The secondary analysis included (adjusted) regression analysis to investigate factors associated with contraception use with the variables of interest being gender roles and decision-making, whilst considering demographic and socio-economic controls. RESULTS: The secondary data analysis found gender roles were associated with current/ever use of contraceptives as reported by the respondents. Socio-economic factors such as husband's and wife's education and gender roles such as indicators showing sharing of childcare responsibilities affected contraceptive use positively. However, decision making regarding contraceptive use was not found to be associated with current/ever use of contraceptives. CONCLUSION: Gender has a role in the use of contraceptive, however decision-making may not be associated with contraceptive use. Educational, health promotional and family planning programmes are recommended to promote use of contraceptives. It is important that husbands get involved in these programmes to encourage discussions related to contraceptive use.

Student feedback delivery modes: A qualitative study of student and lecturer views.

BACKGROUND: Student feedback on assessment is fundamental for promoting learning. Written feedback is the most common way of providing feedback yet this has been criticised by students for its ineffectiveness. Given the wide range of feedback modes available, (written, audio, video, screencast, face-to-face, self and peer-feedback) a better understanding of student and lecturer preferences would facilitate recommendations for optimising feedback delivery. The aim of this study was to explore the experiences and preferences for summative feedback modes of physiotherapy students and lecturers. METHODS: A sample of convenience was used to recruit participants from one undergraduate physiotherapy programme in the UK. A total of 25 students were recruited for three focus groups and five lecturers for semi-structured interviews. Focus groups and individual interviews were guided by a semi-structured interview guideline and carried out by a research assistant who was not involved in teaching on the programme and therefore unknown to participants. Data were analysed using inductive thematic analysis. RESULTS: Three themes were developed in relation to student and lecturer experiences of feedback to date: the importance of dialogue; the value of feed forward; and feedback disparity. From the student perspective, three themes were identified supporting their feedback preference: the importance of human connection; added information from non-verbal communication; valuing the lecturer view. From the lecturer perspective, two themes were identified around feedback preferences: challenges of spoken feedback and the importance of self-assessment. CONCLUSIONS: This study identifies challenges around selecting optimal feedback modes due to the lack of student-lecturer consensus. Students preferred lecturer-led modes, providing the highest quality personal interaction with lecturers (face-to-face, screencast, video, audio). Lecturers most often advocated for student led feedback modes (peer or self-assessment) as a means to students valuing the feedback and developing reflective skills.

The Health of Nepali Migrants in India: A Qualitative Study of Lifestyles and Risks.

:Background: Most health research on Nepali migrant workers in India is on sexual health, whilst work, lifestyle and health care access issues are under-researched. Methods: The qualitative study was carried out in two cities of Maharashtra State in 2017. Twelve focus group discussions (FGDs) and five in-depth interviews were conducted with Nepali male and female migrant workers. Similarly, eight interviews were conducted with stakeholders, mostly representatives of organisations working for Nepali migrants in India using social capital as a theoretical foundation. Results: Five main themes emerged from the analysis: (i) accommodation; (ii) lifestyle, networking and risk-taking behaviours; (iii) work environment; (iv) support from local organisations; and (v) health service utilisation. Lack of basic amenities in accommodation, work-related hazards such as lack of safety measures at work or safety training, reluctance of employers to organise treatment for work-related accidents, occupational health issues such as long working hours, high workload, no/limited free time, discrimination by co-workers were identified as key problems. Nepali migrants have limited access to health care facilities due to their inability to prove their identity. Health system of India also discriminates as some treatment is restricted to Indian nationals. The strength of this study is the depth it offers, its limitations includes a lack of generalizability, the latter is a generic issue in such qualitative research. Conclusion: This study suggests risks to Nepali migrant workers' health in India range from accommodation to workplace and from their own precarious lifestyle habit to limited access to health care facilities. We must conduct a quantitative study on a larger population to establish the prevalence of the above mentioned issues and risks. Furthermore, the effectiveness of Nepali migrant support organisations in mitigating these risks needs to be researched.

Qualitative evaluation of mental health training of auxiliary nurse midwives in rural Nepal.

BACKGROUND AND OBJECTIVES: Mental illness is increasingly recognized as a global health problem. However, in many countries, including Nepal, it is difficult to talk about mental health problems due to the stigma associated with it. Hence a training programme was developed to train auxiliary nurse midwives, who otherwise are not trained in mental health as part of their pre-registration training in rural Nepal, on issues related to maternal mental health. After the training programme a selection of auxiliary nurse midwives were interviewed to establish their views on the training, its usefulness and ways to improve it. METHODS: This qualitative study reports on the analysis of interviews conducted with auxiliary nurse midwives who participated in the training programme. The interviews addressed issues associated with the training programme as well as perceptions around mental health in rural Nepal. Transcripts were thematically analysed. RESULTS: Three themes emerged from analysis: (1) issues related to training; (2) societal attitudes; and (3) support for women. The 'training' theme describes the benefits and limitations of training sessions. 'Societal attitudes' describes society's attitude towards mental health which is largely negative. 'Support' describes the positive behaviour and attitude towards pregnant women and new mothers. CONCLUSION: The study supports the need for continued training for auxiliary nurse midwives who are based in the community. This gives them the opportunity to reach the whole community group and potentially have influence over reduction of stigma; offer support and diagnosis of mental ill-health. There is still stigma around giving birth to a female child which can lead to mental health problems. It is imperative to increase awareness and educate the general public regarding mental health illnesses especially involving family members of those who are affected.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Factors related to choice of place of birth in a district in Nepal.

OBJECTIVE: In Nepal, both percentage of women giving birth at health facility and proportion of birth assisted by skilled birth attendant is very low. The purpose of this research was to identify predictors for choice of place of birth: either at home, primary health care facility (including birthing centres) or at tertiary health care facilites (hospitals and clinics). METHODS: A cross-sectional household survey was conducted in seven village development committee of a district lying in plain area of Nepal: Nawalparasi. A structured interview questionnaire was developed and administered face-to-face. Descriptive analysis along with chi-square test and multinomial logistic regression was used to identify the predictors of giving birth at a health care facility. RESULTS: Women were significantly more likely to give birth at health care facilities compared to home if the distance was less than one hour, belonged to advantaged caste, had radio, television and motorbike/scooter, decision maker for place of birth was husband, reported their frequency of antenatal (ANC) visits at 4 or more and belonged to age group 15-19. CONCLUSION: The analysis indicates that husbands of women giving birth influence the choice of place of birth. The findings highlight importance of having four or more ANC visits to the health institutions and that it should be located within one-hour walking distance. Inequity in utilisation of childbirth services at health institutions exists as showed by low utilisation of such services by disadvantaged caste.

Access to free health-care services for the poor in tertiary hospitals of western Nepal: a descriptive study.

BACKGROUND: Nepal is an underdeveloped country in which half of the total health expenditure is from out-of-pocket payments. Thus, the Government of Nepal introduced universal free health-care services up to the level of district hospitals, and targeted these services to poor and marginalized people in regional and subregional hospitals. The aim of this descriptive study was to explore the implementation and utilization of free health-care services by the target population (poor and marginalized people) in two tertiary-care hospitals in western Nepal, one with a social care unit (Western Regional Hospital) and one without a social care unit (Lumbini Zonal Hospital). METHODS: Medical records maintained by the two hospitals for one Nepali calendar year were collected and analysed, along with information from key informant interviews with staff from each hospital and patient exit interviews. RESULTS: Utilization of free health-care services by poor and marginalized people in the two tertiary-care hospitals was suboptimal: only 8.4% of patients using services were exempted from payment in Western Regional Hospital, whereas it was even fewer, at 2.7%, in Lumbini Zonal Hospital. There was also unintended use of services by nontarget people. Qualitative analysis indicated a lack of awareness of free health-care services among clients, and lack of awareness regarding target groups among staff at the hospitals. Importantly, many services were utilized by people from rural areas adjoining the district in which the hospital was situated. CONCLUSION: Utilization of free health-care services by the target population in the two tertiary-care hospitals was very low. This was the result of poor dissemination of information about the free health-care programme by the hospitals to the target population, and also a lack of knowledge regarding free services and target groups among staff working in these hospitals. Thus, it is imperative to implement educational programmes for hospital staff and for poor and marginalized people. Unintended use of free services was also seen by nontarget groups; this suggests that there should further simplification of the process to identify target groups.