Ethical dilemmas in conducting qualitative, public health research on social media: using a study on Facebook as a case.

AIM: Platforms on social media are increasingly used for public health research. While social media provides an exceptional opportunity to explore communication about public health topics, this practice is not without ethical dilemmas. Our aim was to identify and unfold some of these dilemmas and to suggest possible solutions and ways forward for future research. METHODS: Using our own research within a closed forum for people experiencing suicidal thoughts as a case, we explored certain dilemmas and possible answers relating to whether what is to be researched falls under a public or private social media domain; we investigated avenues for obtaining access to participants in an evolving online environment; how to secure informed consent from participants; and ways of ensuring anonymity. RESULTS: We provide recommendations and reflections that we hope will offer inspiration for researchers embarking on similar social media public health research within and beyond suicide research. CONCLUSIONS: The ethical framework commonly referred to in health research, based on confidentiality, anonymity, informed consent and doing no harm must be adjusted to be relevant for a social media context where technologies and regulations are constantly being altered.

The role of alcohol use in pesticide suicide and self-harm: a scoping review.

PURPOSE: Suicide and self-harm by pesticide self-poisoning is common in low- and middle-income countries (LMICs). Alcohol is an important risk factor for self-harm; however, little is known about its role in pesticide self-poisoning. This scoping review explores the role that alcohol plays in pesticide self-harm and suicide. METHODS: The review followed the Joanna Briggs Institute scoping review guidance. Searches were undertaken in 14 databases, Google Scholar, and relevant websites. Articles were included if they focussed on pesticide self-harm and/or suicide and involvement of alcohol. RESULTS: Following screening of 1281 articles, 52 were included. Almost half were case reports (n = 24) and 16 focussed on Sri Lanka. Just over half described the acute impact of alcohol (n = 286), followed by acute and chronic alcohol use (n = 9), chronic use, (n = 4,) and only two articles addressed harm to others. One systematic review/meta-analysis showed increased risk of intubation and death in patients with co-ingested alcohol and pesticides. Most individuals who consumed alcohol before self-harming with pesticides were men, but alcohol use among this group also led to pesticide self-harm among family members. Individual interventions were recognised as reducing or moderating alcohol use, but no study discussed population-level alcohol interventions as a strategy for pesticide suicide and self-harm prevention. CONCLUSION: Research on alcohol's role in pesticide self-harm and suicide is limited. Future studies are needed to: further assess the toxicological effects of combined alcohol and pesticide ingestion, explore harm to others from alcohol including pesticide self-harm, and to integrate efforts to prevent harmful alcohol use and self-harm.

"It is because the treatment of this lady is a cascade": Accumulation of delays and the occurrence of obstetric emergencies in an urban maternity unit in Tanzania.

OBJECTIVE: To explore healthcare workers' and women's experiences of providing and seeking childbirth care in a busy urban maternity facility in Tanzania. DESIGN: A qualitative study with observations, in-depth interviews, and informal conversations, using thematic network analysis. SETTING: This study was conducted in a busy urban maternity unit in Dar es Salaam, Tanzania which is a low-resource setting with a need to improve childbirth care. PARTICIPANTS: Six frontline healthcare providers and four hospital managers from the facility, along with six postpartum women who gave birth at the facility. FINDINGS: Delays were observed throughout the childbirth care cascade, encompassing various stages. During antenatal care, timely provision of care was hindered by a high patientto-provider ratio, resulting in inadequate monitoring of risk factors. At the onset of labor, women delayed seeking care, sometimes, attempting a trial of labor after a previous Caesarean section. Within the facility, delays in care decision-making and patient management were evident due to insufficient resources. The accumulation of these delays over time influenced the quality of care provided and challenged the management of obstetric emergencies at the study facility. KEY CONCLUSIONS: The study findings show that delays are prevalent throughout the entire childbirth care cascade. The accumulation of these delays over time has influenced the quality of care provided at the facility and increased the vulnerability of women experiencing obstetric emergencies. To effectively address the imperative of reducing maternal mortality in low-resource settings, it is essential to develop appropriate interventions that span the entire spectrum of childbirth care. Additionally, further research is needed to delve into the complexities of care decision-making and the quality of care delivered within urban maternal facilities. IMPLICATIONS FOR PRACTICE: Our findings stress the need for comprehensive childbirth interventions and contextspecific guidelines to address challenges across the care cascade, particularly in lowresource settings. Urgent attention is required to prioritize care during patient triage and address systemic challenges within the healthcare system to improve birth outcomes and ensure effective facility-based care provision. TRIAL REGISTRATION NUMBER: NCT04685668 Date of initial trial registration: December 28th, 2020.

Maternal responsibility and omission of complexity: an exploration of the portrayal of gestational diabetes mellitus in Danish written media.

OBJECTIVES: Gestational diabetes mellitus (GDM) has implications for the future health of both mother and offspring, and there is a risk that mothers are held responsible and blamed for their own and their offspring's long-term health. The media plays a significant role in shaping public perceptions of health. Therefore, our study aimed to investigate how GDM and women with GDM are portrayed in Danish written media. DESIGN: We identified written newspaper articles reporting on GDM from 2018 to 2019 and analysed them using thematic network analysis and elements from critical discourse analysis. RESULTS: In total, 130 articles were included in the analysis. Four themes emerged: (1) ways of introducing GDM, (2) descriptions of causes and prevention of GDM, (3) descriptions of consequences of GDM and (4) value-laden descriptions of GDM. GDM was often mentioned in relation to other conditions or factors and with lack of differentiation. Maternal responsibility was emphasised via oversimplified descriptions of causal relations, descriptions of individual agency and no emphasis on structural causes and preventive measures. GDM was positioned as resulting in 'bad pregnancies' using value-laden wordings. CONCLUSION: We identified various aspects of how GDM is portrayed in written media. The findings signal the importance of clear, nuanced and respectful communication on GDM, including conveying the complexity of the condition and the role of structural factors.

A lethal cocktail - shining a light on the relationship between alcohol use and pesticide self-poisoning.

INTRODUCTION: Alcohol and pesticides are toxic substances that each cause acute and chronic harm to humans. Alcohol plays an important and complex role in pesticide self-poisoning, involving toxicological, public health, and social aspects important for research, prevention, and interventions. ALCOHOL USE DISORDER AND SOCIAL HARMS: While the evidence on alcohol co-ingestion in the context of pesticide self-poisoning is limited, it appears that alcohol use increases complications. Even fewer studies address alcohol use disorder and dependence among pesticide self-poisoning patients. The harmful use of alcohol also impacts social life, families, and communities in several ways, including pesticide self-poisoning among individuals around the alcohol user. This, however, is vastly understudied. OUTSIDE INFLUENCES: Agrochemicals and alcohol are produced by industries with financial interests, and the outcome of individual acts of pesticide self-poisoning depends on the lethality of the pesticide purchased and ingested. The promotion of acutely toxic pesticides by companies must be acknowledged within this issue. CONCLUSION: The relationship between alcohol and pesticide self-poisoning is increasingly clear, but more studies are needed to guide management. We cannot ignore that pesticide self-poisoning and harmful use of alcohol occur within the context of wider, often structural, stressors and are influenced by commercial entities.

Alcohol use, self-harm and suicide: a scoping review of its portrayal in the Sri Lankan literature.

Background: Suicide is a global public health problem. Compared to other middle-income countries, much literature has been generated on the topic of self-harm and suicide in Sri Lanka. Harmful use of alcohol is a well-known risk factor to self-harm and suicide, however the connection needed further exploration. Aim: The aim was to investigate alcohol's role in self-harm and suicide in Sri Lanka to inform policy and prevention programs and future research priorities. Methods: We performed a scoping review exploring how the association between alcohol use, self-harm and suicide in Sri Lanka is presented in scientific literature from August 1, 2008 to December 31, 2022. Thematic analysis was used to explore emerging themes. Results: Altogether 116 peer-reviewed articles were included. Three themes emerged: (i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. The articles' recommendations for policy, prevention and research priorities included: Family- and community-based alcohol, self-harm and suicide reduction interventions; viewing self-harm as a window of opportunity for health personnel to intervene in families affected by harmful alcohol consumption; and introduction of and increased access to treatment of alcohol use disorder at the individual level. Conclusion: Suggestions for alcohol, self-harm, and suicide prevention interventions were primarily targeted at the community, though this might also reflect the limited treatment, mental health, and alcohol support available in the country. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm prevention and treatment.

Making Sense or Non-Sense? Communicating COVID-19 Guidelines to Young Adults at Danish Folk High Schools.

Little is known about young people's behaviors and responses under outbreaks of infectious diseases such as the COVID-19 pandemic, especially in institutional settings. This research investigated the reactions of young adults residing at Danish folk high schools (FHSs) towards COVID-19 guidelines and the communicative styles used to enforce COVID-19 guidelines. The qualitative data consists of focus group discussions (FGDs) with students, interviews with staff, and participant observations, as well as survey data from 1800 students. This study showed that young adults reacted negatively when first faced with the new reality of COVID-19 restrictions. They expressed distress over the loss of meaning (non-sense), loss of sense of community, as well as uncertainty. Hygiene guidelines, however, made immediate sense and were socially well accepted. Most FHSs actively involved students in risk communication and creative examples of community-building communication were identified. This study demonstrates that successful risk communication at educational institutions must take into consideration how young adults make sense of and cope with the uncertainties of life during crisis situations including epidemics.

Evaluating the programme and behavior change theories of a community alcohol education intervention in rural Sri Lanka: a study protocol.

Risky alcohol use is a major public health problem globally and in Sri Lanka. While a reduction in alcohol consumption can result in physical, mental, and social benefits, behaviour change is difficult to achieve. Effective, context-adapted interventions are required to minimise alcohol-related harm at a community level. THEATRE is a complex, community-based intervention evaluating whether a promising Sri Lankan pilot study that utilised arts-based research to moderate alcohol use can be scaled up. While the scaled-up pilot study protocol is presented elsewhere, the aim of this protocol paper is to describe the intervention programme theory and evaluation design, and modifications made to the study resulting from COVID-19 and the financial crisis. Drawing on the Behaviour Change Wheel (BCW) and Theoretical Domains Framework, behaviour change theories are presented with potential pathways to guide implementation and evaluation. Alcohol consumption patterns and context of drinking is detailed. The multifaceted intervention targets individuals and communities using arts-based interventions. Four of nine BCW functions are employed in the design of the intervention: education, persuasion, modelling and enablement, and training. Modifications made to the study due to COVID-19 and the financial crisis are described. Ethical approval was obtained from the Ethics Review Committee, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (ERC/2018/21-July 2018 and Feb 2022) and the University of Sydney (2019/006). Findings will be disseminated locally to community members and key stakeholders and via international peer-reviewed publications.

Non-communicable diseases: harnessing the current opportunities.

Non-communicable diseases (NCDs) are receiving growing attention, which brings a unique opportunity to utilise solutions available to address them. These diseases are largely preventable; proven, cost-effective interventions are available; and when NCDs emerge, means exist to treat them, prevent complications, and to improve quality of life. Yet, there is a lack in progress in responding effectively to NCDs, and the current discussion and research focus predominantly on challenges rather than the opportunities, which this paper outlines.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study.

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen - safe and respectful clinical childbirth care - is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study).

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.

The injustice of unfit clinical practice guidelines in low-resource realities.

To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.

A qualitative exploration of rural and semi-urban Sri Lankan men's alcohol consumption.

Harmful alcohol drinking can have health and socio-economic consequences. However, consumption is also associated with pleasure and symbolic meanings. Alcohol intake is increasing in Sri Lanka. In-depth explorations of alcohol patterns are needed to inform interventions and policies. Qualitative data were collected over 11 months in 2014 and 2015 in the North Central Province of Sri Lanka. Ten focus group discussions were conducted in gender, age and geographically (rural and semi-urban) segregated groups. Observations were conducted at alcohol selling establishments and social gatherings. Bourdieu's concepts practice, habitus, symbolic capital and distinction were used for the analysis. Three groups of consumers emerged: moderate consumers, abstainers and heavy drinkers. They each exercised distinctions through social codes of conduct within and towards other groups of consumers. Symbolic capital was expressed through choice of alcohol. Norms of 'acceptable consumption' were defined as 'moderate drinking' in covert, social and contained settings. Public, uncontrolled and solitary consumption violated norms of appropriate consumption. Young consumers communicated a 'modern lifestyle' through their consumption. This study found that alcohol practices mirrored social norms in this Sri Lankan setting. Alcohol and drug prevention and intervention efforts should take this into account.

'We lost because of his drunkenness': the social processes linking alcohol use to self-harm in the context of daily life stress in marriages and intimate relationships in rural Sri Lanka.

INTRODUCTION: Harmful alcohol use has been found to cause detriment to the consumers and those around them. Research carried out in Sri Lanka has described the socioeconomic consequences to families owing to alcohol consumption. However, the social processes around alcohol use and how it could result in behaviour such as self-harm was unclear. With an outset in daily life stressors in marriages and intimate relationships we explored alcohol use in families with a recent case of self-harm. METHODS: Qualitative data were collected for 11 months in 2014 and 2015 in the North Central and North Western provinces of Sri Lanka. Narrative life story interviews with 19 individuals who had self-harmed where alcohol was involved and 25 of their relatives were conducted. Ten focus group discussions were carried out in gender and age segregated groups. An inductive content analysis was carried out. RESULTS: Participants experienced two types of daily life stressors: non-alcohol-related stressors, such as violence and financial difficulties, and alcohol-related stressors. The alcohol-related stressors aggravated the non-alcohol-related daily life stressors within marriages and intimate relationships, which resulted in conflict between partners and subsequent self-harm. Women were disproportionately influenced by daily life stressors and were challenged in their ability to live up to gendered norms of marriage. Further, women were left responsible for their own and their husband's inappropriate behaviour. Self-harm appeared to be a possible avenue of expressing distress. Gendered alcohol and marriage norms provided men with acceptable excuses for their behaviour, whether it was alcohol consumption, conflicts or self-harm. CONCLUSIONS: This study found that participants experienced both alcohol-related and non-alcohol-related daily life stressors. These two categories of daily life stressors, gender inequalities and alcohol norms should be considered when planning alcohol and self-harm prevention in this setting. Life situations also reflected larger community and structural issues.

An investigation into the role of alcohol in self-harm in rural Sri Lanka: a protocol for a multimethod, qualitative study.

INTRODUCTION: Sri Lanka has one of the highest suicide and self-harm rates in the world and although alcohol has been found to be a risk factor for self-harm in Sri Lanka, we know little about the connection between the two. This paper comprises a protocol for a qualitative study investigating alcohol's role in self-harm in rural Sri Lanka at three levels: the individual, community and policy level. The analysis will bring new understanding of the link between alcohol and self-harm in Sri Lanka, drawing on structural, cultural and social concepts. It will equip researchers, health systems and policy makers with vital information for developing strategies to address alcohol-related problems as they relate to self-harm. METHODS AND ANALYSIS: To capture the complexity of the link between alcohol and self-harm in the Anuradhapura district in the North Central Province in Sri Lanka, qualitative methods will be utilised. Specifically, the data will consist of serial narrative life-story interviews with up to 20 individuals who have non-fatally self-harmed and where alcohol directly or indirectly was involved in the incidence as well as with their significant others; observations in communities and families; six focus group discussions with community members; and key-informant interviews with 15-25 stakeholders who have a stake in alcohol distribution, marketing, policies, prevention and treatment as they relate to self-harm. ETHICS AND DISSEMINATION: The study has received ethical approval from the Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka. A sensitive data collection technique will be used and ethical issues will be considered throughout the study. RESULTS: The results will be disseminated in scientific peer-reviewed articles in collaboration with Sri Lankan and other international research partners.