Improving care for immigrant women before, during, and after childbirth - what can we learn from regional interventions within a national program in Sweden?

BACKGROUND: Migration has increased the number of immigrant women in western countries, which has led to a need to adapt sexual and reproductive health (SRH) care to a larger variety of experiences. Examples of problems are poor access/utilization of SRH services among migrants and a comparatively higher rate of mortality and morbidity in relation to pregnancy, especially among those from low- and middle-income settings. Attempts to improve SHR care must consider the complexity of both the problem and the system. A national program to improve women's health in Sweden provided opportunities to study interventions aimed at immigrant women, using a complexity theory lens. The purpose was to explore the characteristics and complexity of regional interventions aiming to improve care and health of immigrant women before, during and after childbirth, and provide knowledge on how regional healthcare actors perceive and address problems in these areas. METHODS: This archival research study is based on qualitative data from detailed yearly reports of all regional program interventions (n = 21 regions) performed between January 2017 and January 2019. The archival data consists of the regional actors' answers to an extensive questionnaire-like template, where the same questions were to be filled in for each reported intervention. Data analyses were performed in several steps, combining classic and directive content analysis. RESULTS: Six problem categories were addressed by 54 regional interventions, 26 directed at immigrant women and their families, 11 at healthcare staff, and 17 at the organizational system. The simple level interventions (n = 23) were more unilateral and contained information campaigns, information material and translation, education, mapping e.g., of genital mutilation, and providing staff and/or financial resources. The complicated interventions (n = 10) concerned increasing communication diversity e.g., by adding iPads and out-reach visits. The complex interventions (n = 21), e.g., health schools, integration of care, contained development, adaptions, and flexibility with regards to the immigrant women's situation, and more interaction among a diversity of actors, also from the wider welfare system. CONCLUSIONS: It is important that complex problems, such as ensuring equal care and health among a diverse population, are addressed with a mix of simple, complicated, and complex interventions. To enhance intended change, we suggest that pre-requisites e.g., communication channels and knowledge on behalf of immigrant women and staff, are ensured before the launch of complex interventions. Alternatively, that simple level interventions are embedded in complex interventions.

Exploring the potential of a multi-level approach to improve capability for continuous organizational improvement and learning in a Swedish healthcare region.

BACKGROUND: Eldercare and care of people with functional impairments is organized by the municipalities in Sweden. Improving care in these areas is complex, with multiple stakeholders and organizations. Appropriate strategies to develop capability for continuing organizational improvement and learning (COIL) are needed. The purpose of our study was to develop and pilot-test a flexible, multilevel approach for COIL capability building and to identify what it takes to achieve changes in key actors' approaches to COIL. The approach, named "Sustainable Improvement and Development through Strategic and Systematic Approaches" (SIDSSA), was applied through an action-research and action-learning intervention. METHODS: The SIDSSA approach was tested in a regional research and development (R&D) unit, and in two municipalities handling care of the elderly and people with functional impairments. Our approach included a multilevel strategy, development loops of five flexible phases, and an action-learning loop. The approach was designed to support systems understanding, strategic focus, methodological practices, and change process knowledge - all of which required double-loop learning. Multiple qualitative methods, i.e., repeated interviews, process diaries, and documents, provided data for conventional content analyses. RESULTS: The new approach was successfully tested on all cases and adopted and sustained by the R&D unit. Participants reported new insights and skills. The development loop facilitated a sense of coherence and control during uncertainty, improved planning and problem analysis, enhanced mapping of context and conditions, and supported problem-solving at both the individual and unit levels. The systems-level view and structured approach helped participants to explain, motivate, and implement change initiatives, especially after working more systematically with mapping, analyses, and goal setting. CONCLUSIONS: An easily understood and generalizable model internalized by key organizational actors is an important step before more complex development models can be implemented. SIDSSA facilitated individual and group learning through action-learning and supported systems-level views and structured approaches across multiple organizational levels. Active involvement of diverse organizational functions and levels in the learning process was facilitated. However, the time frame was too short to fully test all aspects of the approach, specifically in reaching beyond the involved managers to front-line staff and patients.

Collaborative and partnership research for improvement of health and social services: researcher's experiences from 20 projects.

BACKGROUND: Getting research into policy and practice in healthcare is a recognised, world-wide concern. As an attempt to bridge the gap between research and practice, research funders are requesting more interdisciplinary and collaborative research, while actual experiences of such processes have been less studied. Accordingly, the purpose of this study was to gain more knowledge on the interdisciplinary, collaborative and partnership research process by investigating researchers' experiences of and approaches to the process, based on their participation in an inventive national research programme. The programme aimed to boost collaborative and partnership research and build learning structures, while improving ways to lead, manage and develop practices in Swedish health and social services. METHODS: Interviews conducted with project leaders and/or lead researchers and documentation from 20 projects were analysed using directed and conventional content analysis. RESULTS: Collaborative approaches were achieved by design, e.g. action research, or by involving practitioners from several levels of the healthcare system in various parts of the research process. The use of dual roles as researcher/clinician or practitioner/PhD student or the use of education designed especially for practitioners or 'student researchers' were other approaches. The collaborative process constituted the area for the main lessons learned as well as the main problems. Difficulties concerned handling complexity and conflicts between different expectations and demands in the practitioner's and researcher's contexts, and dealing with human resource issues and group interactions when forming collaborative and interdisciplinary research teams. The handling of such challenges required time, resources, knowledge, interactive learning and skilled project management. CONCLUSIONS: Collaborative approaches are important in the study of complex phenomena. Results from this study show that allocated time, arenas for interactions and skills in project management and communication are needed during research collaboration to ensure support and build trust and understanding with involved practitioners at several levels in the healthcare system. For researchers, dealing with this complexity takes time and energy from the scientific process. For practitioners, this puts demands on understanding a research process and how it fits with on-going organisational agendas and activities and allocating time. Some of the identified factors may be overlooked by funders and involved stakeholders when designing, performing and evaluating interdisciplinary, collaborative and partnership research.

Evidence-informed policy formulation and implementation: a comparative case study of two national policies for improving health and social care in Sweden.

BACKGROUND: Evidence has come to play a central role in health policymaking. However, policymakers tend to use other types of information besides research evidence. Most prior studies on evidence-informed policy have focused on the policy formulation phase without a systematic analysis of its implementation. It has been suggested that in order to fully understand the policy process, the analysis should include both policy formulation and implementation. The purpose of the study was to explore and compare two policies aiming to improve health and social care in Sweden and to empirically test a new conceptual model for evidence-informed policy formulation and implementation. METHODS: Two concurrent national policies were studied during the entire policy process using a longitudinal, comparative case study approach. Data was collected through interviews, observations, and documents. A Conceptual Model for Evidence-Informed Policy Formulation and Implementation was developed based on prior frameworks for evidence-informed policymaking and policy dissemination and implementation. The conceptual model was used to organize and analyze the data. RESULTS: The policies differed regarding the use of evidence in the policy formulation and the extent to which the policy formulation and implementation phases overlapped. Similarities between the cases were an emphasis on capacity assessment, modified activities based on the assessment, and a highly active implementation approach relying on networks of stakeholders. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was empirically useful to organize the data. CONCLUSIONS: The policy actors' roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be useful. However, it provided insufficient guidance for analyzing actors involved in the policy process, capacity-building strategies, and overlapping policy phases. A revised version of the model that includes these aspects is suggested.

The impact of a computer assisted learning programme on the ability to interpret cardiotochography. A before and after study.

OBJECTIVE: To evaluate if a computer assisted learning programme could bring about a higher degree of individuals who correctly classified cardiotochography (CTG) recordings in a non-selected population of midwives and physicians. STUDY DESIGN: A before and after study. SETTING: Södersjukhuset, Stockholm, Sweden. SUBJECTS: One hundred and thirty midwives and 49 physicians at the maternity unit, September 2009-April 2010. A computer assisted learning programme for interpreting CTG patterns has been created. All 179 individuals included made the first interpretation and the 135 individuals also completing the education made the second interpretation. A third randomly selected interpretation was performed immediately following the second; permitting two participants to classify a CTG together. Comparison between the before and after-test was based on the Fisher exact test. MAIN OUTCOME MEASURE: The proportion of individuals who correctly classified CTGs before and after the training. RESULTS: Sixty four percentage of the individuals classified the CTGs correctly before and 66% after the training (P=0.76). There was no difference between the two professional groups. Normal CTGs were correctly identified by 36% of the individuals before and in 80% after the training (P=0.065). Corresponding figures for pathological CTGs were 83% and 85% (P=1.00), respectively. CONCLUSION: We found no improvement in the proportion of individuals who classified CTGs correctly after the completion of a computer assisted learning programme in fetal monitoring. The baseline level of competence was higher than expected.

Subjective orthodontic treatment need and perceived dental appearance among young Finnish adults with and without previous orthodontic treatment.

Subjective orthodontic treatment need and perceived oral condition were studied in a sample of 226 young adult Finns with and without previous orthodontic treatment. The subjects, applicants to enter the University of Helsinki, were interviewed immediately after their entrance examination. Altogether 38.5 per cent of the subjects had received some form of orthodontic treatment. A higher percentage of subjects who had been orthodontically treated reported a current subjective need for treatment than did the untreated ones but this only reached statistical significance in men (P < 0.05). Appearance was the reason for the treatment need among 64.7 per cent of treated and among 80.0 per cent of untreated subjects. The differences in proportions were non-significant. Men were more often satisfied with their dentition than women. Most, 56.3 per cent of treated and 66.2 per cent of untreated subjects, considered their anterior teeth regularly positioned. The most prevalent type of malocclusion noted in the anterior segments was crowding (27.0 per cent), followed by malpositioned (18.6 per cent) and protruding (9.3 per cent) teeth. It is likely that those who had received orthodontic treatment, had initially had more, and more severe malocclusions than those who were untreated. Thus, it may be that orthodontic treatment had raised the perceptions of the dentition of the treated individuals to the same level as the untreated individuals.