Family and community resilience: a Photovoice study.

BACKGROUND: Adverse childhood experiences (ACEs), in combination with adverse community environments, can result in traumatic stress reactions, increasing a person's risk for chronic physical and mental health conditions. Family resilience refers to the ability of families to withstand and rebound from adversity; it involves coping with disruptions as well as positive growth in the face of sudden or challenging life events, trauma, or adversities. This study aimed to identify factors contributing to family and community resilience from the perspective of families who self-identified as having a history of adversity and being resilient during the COVID-19 pandemic. METHODS: This study used Photovoice, a visual participatory research method which asks participants to take photographs to illustrate their responses to a research question. Participants consisted of a maximum variation sample of families who demonstrated family level resilience in the context of the pair of ACEs during the COVID-19 pandemic. Family members were asked to collect approximately five images or videos that illustrated the facilitators and barriers to well-being for their family in their community. Semi-structured in-depth interviews were conducted using the SHOWeD framework to allow participants to share and elucidate the meaning of their photos. Using thematic analysis, two researchers then independently completed line-by-line coding of interview transcripts before collaborating to develop consensus regarding key themes and interpretations. RESULTS: Nine families were enrolled in the study. We identified five main themes that enhanced family resilience: (1) social support networks; (2) factors fostering children's development; (3) access and connection to nature; (4) having a space of one's own; and (5) access to social services and community resources. CONCLUSIONS: In the context of additional stresses related to the COVID-19 pandemic, resilient behaviours and strategies for families were identified. The creation or development of networks of intra- and inter-community bonds; the promotion of accessible parenting, housing, and other social services; and the conservation and expansion of natural environments may support resilience and health.

Action against inequalities: a synthesis of social justice & equity, diversity, inclusion frameworks.

Inequalities in health have long been recognized as interconnected with social, economic, and various other inequalities. The application of social justice and equity, diversity, inclusion (EDI) frameworks may help expand interdisciplinary perspectives in addressing inequalities. This review study conducted an environmental scan for existing syntheses of theories, models, and frameworks (TMFs) relevant to the social justice and EDI. Results from Web of Science, Scopus, PubMed, CINAHL, PsychINFO, and MEDLINE retrieved an existing implementation science framework intently centered upon health inequalities, and draws from a synthesis of postcolonial theory, reflexivity, intersectionality, structural violence, and governance theory. Given this high degree of relevance to the objective of this review, the framework was selected as a basis for expanded synthesis. Subsequent processes sought to identify social justice TMFs which could be integrated into the base framework selected, as well as to refine scope of the study. Based upon considerations of level of evidence and non-tokenistic integration, the following social justice and EDI TMFs were identified: John Rawls' theory of justice; Amartya Sen's Capabilities Approach; Iris Marion Young's theories of justice; Paulo Freire's critical consciousness; and critical race theory (CRT). The focus of the synthesis performed was scoped towards minimizing potential harms arising from actions intending to reduce inequalities. EDI considerations were not collated into a singular construct, but rather extended as a separate component assessing inequitable distribution of risks and benefits given population heterogeneity. Reflexive analysis amended the framework with two key decisions: first, the integration of environmental justice into a single construct, which helps to inform Rawls' and Sen's TMFs; second, a temporal element of sequential-analysis was employed over a unified output. The result of synthesis consists of a three-component framework which: (1) presents sixteen constructs drawn from selected TMFs, to consider various harms or potential reinforcement of existing inequalities; (2) aims to de-invisibilize marginalized groups who are noted to experience inequitable outcomes, and acknowledges the presence of individuals belonging to multiple groups; and (3) synthesizes seven considerations related to equitable dissemination and evaluation as drawn from TMFs, separated for sequential analysis after assessment of harms.

Elevations in Blood Pressure Associated with Exposure to Violence are Mitigated by Pro-gun-Carrying Attitudes among Street-Identified Black Males and Females.

Living in neighborhoods with elevated rates of violent crime, such as in many poor Black American communities, is a risk factor for a range of physical and mental health challenges. However, the individual different factors that influence health outcomes in these stressful environments remain poorly understood. This study examined relations between exposure to violence, gun-carrying attitudes, and blood pressure in a community sample of street-identified Black American boys/men and girls/women. Survey data and blood pressure were collected from 329 participants (ages 16-54; 57.1% male) recruited from two small urban neighborhoods with high rates of violence using street participatory action research methodology. Results revealed that systolic blood pressure was elevated in the sample as was exposure to severe forms of direct and vicarious violence (e.g., shootings, assault). Attitudes about carrying guns moderated associations between the degree of violence exposure endorsed by participants and both systolic and diastolic blood pressure. Specifically, the positive association between exposure to violence and both systolic and diastolic blood pressure at low levels of pro-gun-carrying attitudes was no longer apparent at high levels of pro-gun attitudes. Furthermore, pro-gun attitudes appeared to moderate the association between exposure to violence and systolic pressure for older participants but not younger participants. Results suggest that positive attitudes about carrying guns (presumably indicative of pro-gun-carrying behavior) weakened the link between violence exposure and blood pressure. These novel findings suggest that carrying a gun may protect against the harmful effects of chronic stress from violence exposure on physical health outcomes (i.e., hypertension) among street-identified Black Americans.

Targeting emotion dysregulation in depression: an intervention mapping protocol augmented by participatory action research.

BACKGROUND: Depression is a highly prevalent and often recurrent condition; however, treatment is not always accessible or effective in addressing abnormalities in emotional processing. Given the high prevalence of depression worldwide, identifying and mapping out effective and sustainable interventions is crucial. Emotion dysregulation in depression is not readily amenable to improvement due to the complex, time-dynamic nature of emotion; however, systematic planning frameworks for programs addressing behavioral changes can provide guidelines for the development of a rational intervention that tackles these difficulties. This study proposes an empirical and theoretical art-based emotion regulation (ER) intervention using an integrated approach that combines intervention mapping (IM) with participatory action research (PAR). METHODS: We used the IM protocol to identify strategies and develop an intervention for patients with major depressive disorder (MDD). As applied in this study, IM comprises six steps: (a) determining the need for new treatments and determinants of risk; (b) identifying changeable determinants and assigning specific intervention targets; (c) selecting strategies to improve ER across relevant theories and research disciplines; (d) creating a treatment program and refining it based on consultations with an advisory group; (e) developing the implementation plan and conducting a PAR study to pilot-test it; and (f) planning evaluation strategies and conducting a PAR study for feedback on the initial testing. RESULTS: Following the steps of IM, we developed two frameworks for an art-based ER intervention: an individual and an integrative framework. The programs include four theory- and evidence-based ER strategies aimed mainly at decreasing depressive symptoms and improving ER in patients with MDD. We also developed a plan for evaluating the proposed intervention. Based on our preliminary PAR studies, the intervention was feasible and acceptable for adoption and implementation in primary care settings. CONCLUSION: The application of IM incorporated with PAR has resulted in an intervention for improving ER in depression. While changing behavior is perceived as a challenging and elaborate task, this method can be useful in offering a clear structure for developing rational interventions. Further refinement is necessary through rigorous research.

'It is human work': qualitatively exploring community roles that facilitate cultural food security for people from refugee backgrounds.

OBJECTIVES: Cultural food security is crucial for cultural health and, for people from refugee backgrounds, supports the settlement journey. Cultural communities are vital in facilitating access to cultural foods; however, it is not understood how refugee-background communities sustain cultural food security in the Australian context. This study aimed to explore key roles in refugee-background communities to understand why they were important and how they facilitate cultural food security. DESIGN: Interviews were conducted by community researchers, and data analysis was undertaken using best-practice framework for collaborative data analysis. SETTING: Greater Brisbane, Australia. PARTICIPANTS: Six interviews were conducted between August and December 2022 with people from a refugee-background community, lived in Greater Brisbane and who fulfilled a key food role in the community that facilitated access to cultural foods. RESULTS: Fostering improved cultural food security supported settlement by creating connections across geographical locations and cultures and generated a sense of belonging that supported the settlement journey. Communities utilised communication methods that prioritised the knowledge, wisdom and experience of community members. It also provided community members with influence over their foodways. Community leaders had an ethos that reflected collectivist values, where community needs were important for their own health and well-being. CONCLUSIONS: Communities are inherently structured and communicate in a way that allows collective agency over foodways. This agency promotes cultural food security and is suggestive of increased food sovereignty. Researchers and public health workers should work with communities and recognise community strengths. Food security interventions should target cultural food security and autonomy.

Unveiling injustice: Disrupting child removal policies and upholding breastfeeding: An emancipatory framework.

Before colonization, Aboriginal and Torres Strait Islander communities had nurturing, holistic, and communitarian approaches that promoted extended and healthy lives for their children. Colonization, marked by policies of genocide and assimilation, has resulted in an alarming overrepresentation of Aboriginal and Torres Strait Islander children under the care of child protection agencies, resulting in compromised health outcomes and reduced life expectancies. We are conducting a study designed to enhance positive developmental outcomes for Aboriginal and Torres Strait Islander children by articulating and enabling the rights of mothers and children to breastfeed in the context of a child protection intervention and child removal. To understand and address this problem, it is critical to implement culturally safe, de-colonized, emancipatory research that is guided by and benefits Aboriginal and Torres Strait Islander communities. This article presents an emancipatory framework that we are applying to our study using an Aboriginal participatory action research approach, that serves as a guide for non-Indigenous researchers seeking to conduct research with Indigenous communities. We emphasize the importance of incorporating an Aboriginal participatory action research framework, using community consultation and codesign; culturally secure data collection methods, and paying attention to Indigenous data sovereignty. Developing trusting respectful relationships is conducive to knowledge acquisition, exchange, and use, when research approaches deeply rooted in community involvement are applied. A call to action by the critical midwifery studies collective, urges non-Indigenous researchers to become accountable allies that demonstrates respect for community leadership while actively striving to ensure research does not perpetuate further harm, and produces effective change. This article provides an overview of ways to conduct ethical emancipatory research with Indigenous participants, that is, of benefit to midwifery practitioners and is applicable to many areas of research, policy, and practice.

Patient-Led Research to Develop a Training Programme for Restoring Musical Joy in Cochlear Implant Recipients: A Reflexive Process Evaluation.

BACKGROUND: The role of patients in healthcare research is slowly evolving, although patient roles in the research process are limited. This paper reports on a patient-led research project aiming to develop a musical hearing training programme for patients with a cochlear implant (CI): the Musi-CI programme. A CI is an inner ear prosthesis that allows people with severe hearing loss to hear. However, while speech can be understood, CI users cannot fully enjoy music or feel aversion to it. The Musi-CI programme aims to reduce this music aversion to ultimately improve music enjoyment and social participation. The development of the Musi-CI programme was supported by a consortium of professionals in CI rehabilitation and research. The aim of this paper is to describe and evaluate the Musi-CI programme development process and its impact on professional CI rehabilitation and research. METHODS: Programme development was described using a 3-layered process model of action research, distinguishing the CI user process, the healthcare professional process and the research process. To evaluate perceptions on the programme development process, consortium partners provided written comments and participated in a reflexive evaluation session that was video-recorded. Reflexive evaluation aims for collective learning and strengthening collaboration among participants. Written comments and video data were analysed using template analysis. RESULTS: The involvement of an expert by experience was perceived as challenging but rewarding for all consortium partners, opening up new perspectives on CI-rehabilitation practice and research. Data analysis revealed two themes on the programme development process, professional space and acknowledgement, and two themes on the outcomes on CI rehabilitation and research: critical reflection and paradigm shift. CONCLUSION: Experts by experience represent a different knowledge domain that may contribute to change in rehabilitation and research. PATIENT OR PUBLIC CONTRIBUTION: The development of the programme was initiated by a professional musician and CI user who organized the funding, had a leading role throughout the research process, including the write-up of the results, and co-authored this paper.

Pathways for Strengthening Lived Experience Leadership for Transformative Systems Change: Reflections on Research and Collective Change Strategies.

INTRODUCTION: The Activating Lived Experience Leadership (ALEL) project was a South Australian participatory action research project that aimed to improve the ways lived experience is recognised, valued and integrated across mental health and social sector systems. ALEL was completed during 2019-2021, where it engaged 182 participants in generating community action and research knowledge. OBJECTIVE: Our paper discusses the project's processes of building a collective partnership among lived experience leaders and other leaders from within the sector, so that the actions and strategies identified through research could be implemented by systems-level impact. We describe the collaborative process and key learnings that resulted in eight key action areas for transformative systems change in South Australia. METHODS: The project invited a diverse range of self-identified lived experience and other leaders to be involved in a PAR process featuring formal qualitative research (focus groups, surveys and interviews) as well as community development activities (leaders' summit meetings, consultations, training and community of practice meetings). These processes were used to help us describe the purpose, achievements and potential of lived experience leadership. Project priorities and systems-level analysis was also undertaken with lived experience sector leaders and project advisors across two leaders' summit meetings, integrating research outcomes with sector planning to define high-level actions and a vision for transformational change. RESULTS: Participatory action research as informed by systems change and collective impact strategies assisted the project to generate detailed findings about the experiences and complexities of lived experience leadership, and collective responses of how systems could better support, be accountable to and leverage lived experience perspectives, experience and peer-work approaches. CONCLUSION: Systems change to define, value and embed lived experience leadership benefits from collective efforts in both formal research and sector development activities. These can be used to generate foundational understandings and guidance for working together in genuine ways for transforming mental health and social sector systems, experience and outcomes. PUBLIC CONTRIBUTION: Members of lived experience communities codesigned the project, and contributed to project governance and the development of all findings and project reports.

'I am proud of how I handled it'. Exploring the impact of the COVID-19 pandemic and related restrictions on well-being of adults with severe mental illness using qualitative methods.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and related restrictions globally impacted mental health, particularly for those with pre-existing severe mental illness (SMI). This qualitative study examined how adults with SMI perceived the effects of the COVID-19 pandemic and related restrictions in the Netherlands, focusing on their personal recovery, well-being and daily life, including an exploration of factors influencing these effects. METHODS: Semi-structured interviews were conducted, audio-recorded and transcribed verbatim. Reflexive thematic analysis was applied. Purposive sampling was used to ensure diversity of individuals with SMI (i.e., age, gender, diagnosis, cultural background and mental healthcare institution). RESULTS: Twenty participants (median age: 45 years [SD: 12, 8]; 11 females) were interviewed between May and July 2023. Findings revealed a wide range of experiences: while some individuals reported a negative impact on their existing psychiatric symptoms, others described adaptability, resilience and even positive effects of COVID-19 restrictions on their mental health and well-being. Factors influencing the heterogeneic perceptions of the COVID-19 pandemic and related restrictions include the availability of trusted social relationships and enduring interactions with health professionals. CONCLUSION: Personalised support, both socially and professionally, is crucial for addressing fears, building resilience, reducing isolation and encouraging positive coping strategies for individuals with SMI during external crises. In this project, a participatory research approach that integrated the lived experience perspective helped uncover the unique perceptions of people with SMI with regard to the pandemic and related restrictions. PATIENT OR PUBLIC CONTRIBUTION: The study used a participatory action research approach, with experts-by-experience involved in every stage of the project as part of the research team. This included engagement with the funding application process, recruitment strategies for interviews, developing the interview guide, piloting the interview, interpreting findings, and knowledge dissemination activities.

Facilitators and barriers to implementing a specialized care unit for persons with cognitive impairment in an acute geriatric hospital: a process evaluation.

BACKGROUND: Implementing dementia care interventions in an acute hospital poses multiple challenges. To understand factors influencing the implementation, in-depth knowledge about specific facilitators and barriers is necessary. The aim of this study was to identify facilitators and barriers to implementing an interprofessional, multicomponent intervention of a specialized unit for persons with cognitive impairment in an acute geriatric hospital. METHODS: We conducted a process evaluation as part of a participatory action research study. For data collection, semi-structured individual interviews with fifteen professionals involved in the implementation of the specialized unit. We further conducted two focus groups with twelve professionals working on other units of the geriatric hospital. We performed a qualitative content analysis following Kuckartz's content-structuring analysis scheme. RESULTS: We identified the following barriers to implementing the specialized unit: uncontrollable contextual changes (e.g., COVID-19 pandemic), staff turnover in key functions, high fluctuation in the nursing team, traditional work culture, entrenched structures, inflexible and efficiency-oriented processes, monoprofessional attitude, neglect of project-related communication, and fragmentation of interprofessional cooperation. An established culture of interprofessionalism, an interprofessionally composed project group, cooperation with a research partner, as well as the project groups' motivation and competence of managing change facilitated the implementation. CONCLUSIONS: The implementation faced numerous barriers that can be described using the key constructs of the i-PARIHS framework: context, recipients, innovation, and facilitation. Overcoming these barriers requires an organizational development approach, extended project duration and increased process orientation. Furthermore, strategically planned, precise and ongoing communication towards all persons involved seems crucial. Differences between the work cultures of the professions involved deserve particular attention with regard to project-related roles and processes.

Walking together in friendship: Learning about cultural safety in mainstream mental health services through Aboriginal Participatory Action Research.

OBJECTIVE: Culturally safe service provision is essential to improving social and emotional wellbeing among Aboriginal and Torres Strait Islander communities, and to eliminating health inequities. Cultural safety is about ensuring that all people have a safe and healing journey through services, regardless of their cultural background. In this project, we aim to (1) understand how Aboriginal and Torres Strait Islander peoples conceptualise cultural safety, and (2) co-design a qualitative interview for the next phase of this project, where we plan to learn about experiences of cultural safety within mental health services. METHODS: We conducted six focus groups (in one metro and two regional areas, Western Australia). Following an Aboriginal Participatory Action Research methodology, we yarned with Aboriginal and Torres Strait Islander mental health service users, carers, community members, mental health professionals and Cultural Healers about cultural safety. RESULTS: Participants described a culturally safe service as one where Aboriginal cultural knowledges, life experiences, issues and protocols are understood and acknowledged, and reported that mainstream mental health services are not currently culturally safe. Participants emphasised the importance of building trust, rapport, reciprocity and following appropriate relational processes when designing a qualitative interview for the next phase. CONCLUSIONS: A lack of cultural safety in mental health services is likely to contribute to the disparity in outcomes between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Embedding cultural safety into research design allows for authentic community engagement and facilitates knowledge sharing around ways to improve cultural safety in mental health services.

Evaluation of environmental features that support breastfeeding: A photovoice study.

The United Kingdom (UK) has some of the lowest breastfeeding rates in the world, and Stoke-on-Trent has some of the lowest breastfeeding rates and highest infant mortality rates in the UK. Vicarious experience of formula feeding, formula feeding culture, and a lack of physical environments to support breastfeeding are known barriers to uptake and maintenance. Improving physical environments and increasing the visibility of breastfeeding in public would help to challenge these barriers. This research employs a participatory approach to understand the facilitators and barriers to breastfeeding in public. Nine breastfeeding peer supporters were recruited as co-researcher for a photovoice study. Co-researchers collated images of features in environments which they felt either supported or acted as a barrier to public breastfeeding. An analysis workshop was held to review the data collected and produce collaboratively agreed findings. Various environmental features were highlighted as facilitators to breastfeeding including family rooms, welcoming signage, supportive staff members, and displays of information about breastfeeding. In addition, poorly designed family rooms, lack of inclusivity within breastfeeding spaces, breastfeeding spaces within toilets and a lack of information were barriers to public breastfeeding. This research illustrates that while some environments are well designed to support breastfeeding many others are not. Environments often lack basic provision and/or make token gestures towards breastfeeding support, such as welcome signage, without providing the infrastructure needed to support breastfeeding. More education about breastfeeding friendly spaces and resources for putting this information into practice are needed for environment owners, managers, and policy makers.

Co-creating a continuous leadership development program in rural municipal healthcare - an action research study.

BACKGROUND: An increasingly complex healthcare system entails an urgent need for competent and resilient leadership. However, there is a lack of extensive research on leadership development within healthcare. The knowledge gaps extend to various frameworks and contexts, particularly concerning municipal healthcare, knowledge leadership, and the application of knowledge in the field of practice. This study is the first in a larger action research project that aims to co-create a knowledge-based continuous leadership development program for healthcare in a rural Arctic municipality. This present study aims to explore the knowledge and experiences of the participating healthcare leaders to develop a common basis for co-creating the program. METHODS: This hermeneutical study presents the first cycle of the larger action research project. An appreciative approach facilitated the project. Twenty-three healthcare leaders from three different leadership levels attended and evaluated two leadership development workshops and participated in four focus groups. The data were analyzed using Braun and Clarke's reflexive thematic analysis. RESULTS: Two main themes were identified: (1) changing from striving solo players to team players, and (2) learning to handle a conflicting and complex context. These results influenced how the leadership development program based on the participants' co-creation was organized as a collective and relational process rather than an individual competence replenishment. CONCLUSIONS: The knowledge and experiences of healthcare leaders led to the co-creation of a knowledge-based continuous leadership development program based on the facilitated interaction of four essential elements: (1) competence development, (2) structures for interaction, (3) interpersonal safety, and (4) collective values and goals. The interaction was generated through trusted reflection facilitated by appreciative inquiry. The four elements and core played a crucial role in fostering relationships and facilitating learning, driving transformative change in this leadership development program. The study's results provide a solid foundation for further co-creating the program. However, more research is needed to fully explore the practical application and overall significance.

Optimizing the Maastricht Work-Related Support intervention in clinical patient care: the value of integrating action research into intervention mapping.

BACKGROUND: Healthcare professionals (HCPs) are increasingly recommended to play an important role in supporting people with chronic disease in work participation. An intervention for HCPs to provide work-related support to their patients in clinical care was developed with intervention mapping (Maastricht Work-Related Support; Maastricht WRS). Action research proposes 'combining research and practice', which allows us to incorporate experiences of HCPs while implementing and to realize intervention's full potential. Therefore, the aim of this study is to explore, by integrating action research into an intervention mapping approach, how experiences of HCPs with early implementation can be used to optimize the Maastricht WRS in clinical care. METHODS: Semi-structured interviews were held with nine HCPs (response rate 82%), involved in care for people with inflammatory arthritis, knee problems or inflammatory bowel disease. Some of them were not yet trained in the Maastricht WRS while others had received the training and were providing the Maastricht WRS. RESULTS: All participants regarded WRS an important part of clinical care. Untrained HCPs indicated a lack of knowledge and skills in providing the Maastricht WRS, and a need for tools. Trained HCPs were satisfied with the training and tools, but stressed that practical limitations hindered providing the Maastricht WRS. Action research showed that the intervention meets the needs of HCPs, but need some optimizations: (1) organizing 'intervision' for HCPs, (2) inform and activate patients to discuss work with their HCP, (3) update initial tools and (4) including patients' work status in the electronic patient system. CONCLUSIONS: Action research integrated into intervention mapping proved to improve the Maastricht WRS intervention. By involving HCPs, the intervention could be optimized to provide to support people with chronic diseases in clinical care in healthy and sustainable work participation.

Action researchers as "orchestrators" of co-innovation: a theoretical and methodological framework.

BACKGROUND: With the increasing complexity of health care services, more comprehensive and integrated services need to be designed. Action researchers are encouraged to facilitate multiactor participation and user-centered approaches to initiate service development. However, "orchestrating" co-innovation, in which actors have diverse attitudes, agendas, positions of power, and horizons of understanding, is challenging, and a framework that supports action researchers in co-innovation studies lack. The purpose of this article was to explore how action researchers can facilitate multiactor engagement and handle possible challenges and stimulate creativity among diverse stakeholders. METHODS: We have studied and discussed two Scandinavian cases of rehabilitation innovation (for cancer patients and persons with acquired brain injury) where two research teams with action research approaches have acted in an orchestrating role to create co-innovation. RESULTS: We identified four themes that are essential for action researchers to facilitate collaborative and creative co-innovation processes: (1) relational power reflexibility, (2) resource integration, (3) joint understanding, and (4) the facilitation of creativity. These mutually dependent themes constitute a theoretical and methodological framework for of co-innovation. CONCLUSIONS: This paper offers a contribution that supports action researchers in orchestrating diverse actors and their contributions in co-innovation processes.

Development of the Conversational Health Literacy Assessment Tool for maternity care (CHAT-maternity-care): participatory action research.

BACKGROUND: Limited health literacy in (expectant) parents is associated with adverse health outcomes. Maternity care providers often experience difficulties assessing (expectant) parents' level of health literacy. The aim was to develop, evaluate, and iteratively adapt a conversational tool that supports maternity care providers in estimating (expectant) parents' health literacy. METHODS: In this participatory action research study, we developed a conversational tool for estimating the health literacy of (expectant) parents based on the Conversational Health Literacy Assessment Tool for general care, which in turn was based on the Health Literacy Questionnaire. We used a thorough iterative process including different maternity care providers, (expectant) parents, and a panel of experts. This expert panel comprised representatives from knowledge institutions, professional associations, and care providers with whom midwives and maternity care assistants work closely. Testing, evaluation and adjustment took place in consecutive rounds and was conducted in the Netherlands between 2019 and 2022. RESULTS: The conversational tool 'CHAT-maternity-care' covers four key domains: (1) supportive relationship with care providers; (2) supportive relationship within parents' personal network; (3) health information access and comprehension; (4) current health behaviour and health promotion. Each domain contains multiple example questions and example observations. Participants contributed to make the example questions and example observations accessible and usable for daily practice. The CHAT-maternity-care supports maternity care providers in estimating (expectant) parents' health literacy during routine conversations with them, increased maternity care providers' awareness of health literacy and helped them to identify where attention is necessary regarding (expectant) parents' health literacy. CONCLUSIONS: The CHAT-maternity-care is a promising conversational tool to estimate (expectant) parents' health literacy. It covers the relevant constructs of health literacy from both the Conversational Health Literacy Assessment Tool and Health Literacy Questionnaire, applied to maternity care. A preliminary evaluation of the use revealed positive feedback. Further testing and evaluation of the CHAT-maternity-care is required with a larger and more diverse population, including more (expectant) parents, to determine the effectiveness, perceived barriers, and perceived facilitators for implementation.

Developing a capacity-building intervention for healthcare workers to improve communication skills and awareness of hard of hearing and D/deaf patients: results from a participatory action research study.

BACKGROUND: Healthcare workers (HCWs) are commonly not prepared to properly communicate with D/deaf and hard of hearing (HoH) patients. The resulting communication challenges reinforce the existing barriers to accessing and benefiting from quality of care in these populations. In response, this study aimed to develop and evaluate a capacity-building intervention for HCWs to raise their awareness of D/deaf and HoH individuals' experiences in healthcare and improve their capacity to communicate with these populations. METHODS: This study featured a participatory action research design using qualitative and quantitative methods. The intervention was developed and tested through 4 iterative phases. Reactions (i.e., satisfaction and perception of the intervention content, quality, appropriateness and usefulness) were assessed quantitatively and qualitatively after the intervention, whereas perceived knowledge and self-efficacy in communicating with D/deaf and HoH patients and organizational payoffs (use frequency of basic rules and tools improving communication) were quantitatively assessed before, after and 6-month post-intervention. RESULTS: Main qualitative and quantitative findings showed that the final version of the intervention reached high levels of satisfaction among participants. Next, perceived knowledge and self-efficacy scores obtained after receiving the intervention and 6 months later were significantly higher than those yielded in the initial assessment, although both scores significantly decreased at 6 months (compared to the scores obtained just after the intervention). Finally, findings showed no significant changes in organizational payoffs after receiving the intervention. Echoing these results, main qualitative findings documented that after receiving the intervention, participants felt more confident yet not more equipped to communicate with D/deaf and HoH patients. CONCLUSIONS: Findings suggest that the capacity-building intervention is a promising means to sustainably increase HCWs' perceived knowledge and self-efficacy on how communicating with D/deaf and HoH patients, although complementary approaches and follow-up intervention reminders may be necessary to enable practice changes in the working environment.

Optimising remote health workforce retention: protocol for a program of research.

BACKGROUND: Nowhere is optimising healthcare staff retention more important than in primary health care (PHC) settings in remote Australia, where there are unacceptably high rates of staff burnout and turnover. Ensuing consequences for the remote health services and the community are acute - staffing shortfalls in clinics; organisational instability; excessive costs associated with frequent staff recruitment and orientation; diminished access to PHC for patients in need; and lack of continuity of patient care; all of which further entrench poor health outcomes for the community. Optimising remote healthcare staff retention is critical in order to provide high quality and continued PHC. Currently, however, there is paucity of knowledge to inform targeted and effective retention strategies in remote health services. This research program seeks to develop a stronger evidence base to understand (i) what retention strategies are effective in improving morale, job satisfaction, intention to remain in the job, and consequent length of service for remote healthcare staff; (ii) how best to 'bundle' these strategies for different health workforce groups; and (iii) how these 'bundles' work in different service contexts. METHODS: This paper describes a five-year implementation research program in partnership with twelve remote Aboriginal and Torres Strait Islander Community Controlled Health Services (ATSICCHS) in the Northern Territory and Queensland, Australia. Overall methodology follows a participatory action research approach which incorporates co-design and realist elements. The program comprises two broad phases involving evidence consolidation and synthesis (Phase 1), and co-design, implementation, and prospective evaluation of 'bundles' of retention strategies (Phase 2) to improve retention of healthcare staff in participating ATSICCHSs. DISCUSSION: This innovative research program has the potential to develop a comprehensive evidence base required to optimise health workforce retention in remote health services. This new evidence will strengthen understanding of what 'bundles' of retention strategies are effective, for which groups of employees, and how they work to improve staff retention.

Experiences of a group of indigenous women from the Colombian Amazon with cervical cancer prevention screening. Qualitative study in the context of participatory research to reduce inequalities.

OBJECTIVES: Despite cervical cancer (CC) being a preventable disease, its incidence remains high in marginalized communities due to inequalities that restrict access to health services. This article investigates the experiences, perceptions, and attitudes regarding the screening of indigenous women in a region of the Colombian Amazon during a cervical cancer prevention initiative facilitated by community participation. DESIGN: Qualitative study based on interviews conducted with women and indigenous leaders from Paujil reserve. They participated in research focused on cervical cancer prevention, which employed a methodology of collaboration between academia and communities aimed at enhancing women's health and reducing inequalities in access to healthcare services. The analysis utilized a deductive and inductive approach. RESULTS: Five main themes were addressed: 'Barriers within health services'; 'Individual and cultural constraints'; 'Motivations and facilitators'; 'Positive experiences within the research framework'; and 'Suggestions for encouraging women's participation.' Challenges related to appointment scheduling and result delivery were frequently cited as obstacles to access. Misinformation, feelings of shame, fear, and distrust towards health services played significant roles in the reluctance to undergo screening. Factors such as support from family and community networks, respectful treatment, ease of scheduling appointments, the presence of female healthcare professionals, and involvement of leaders fluent in indigenous languages were identified as positive facilitators of screening acceptance. CONCLUSION: Understanding the factors that influence access to screening is crucial for reducing inequalities in service delivery for indigenous women. The involvement of trained leaders who can identify these factors and motivate women can have a positive impact on the acceptance and guidance of cervical cancer prevention programs.

PrEP Among Sub-Saharan African Diaspora Communities in Belgium - a Participatory Action Research Study.

In Belgium, migrants from Sub-Saharan Africa (SSA) accounted for 45% of new heterosexual HIV infections in 2021, while only 1.5% of PrEP starters were of SSA descent. We explored the acceptance of PrEP and barriers towards PrEP uptake and use among SSA migrant and diaspora communities in Belgium using a participatory action research approach. Trained community researchers (CRs), involved in all phases of the study, co-designed and moderated group discussions (GDs) while simultaneously providing information on HIV and PrEP during workshops. Extensive summaries and field notes were analysed using reflexive thematic analysis. CRs were involved in data analysis, interpretation and reporting. We conducted seven GDs with 51 participants. We identified five major themes: (1) Participants had limited PrEP knowledge, which created feelings of surprise and annoyance about not being informed. This was partly explained by (2) the taboo and stigma that surrounds sexuality and HIV, which could shape PrEP acceptance. (3) Participants shared feelings of otherness due to experiences of racism and discrimination, also in relationship to HIV prevention. (4) PrEP was considered a high-threshold prevention tool, because of its perceived side-effects and its specialized service delivery. (5) Despite nuanced opinions about PrEP, all participants agreed that PrEP promotion should be mainstreamed, so everyone can make an informed decision. In conclusion, PrEP seemed acceptable among our participants. Our qualitative study provides insights into the intersecting barriers to accessing HIV services, showing that SSA diaspora communities are 'hardly reached' rather than 'hard to reach' by PrEP promotion messages.