Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol.

BACKGROUND: With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements. METHODS: Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation. DISCUSSION: Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

Do dose administration aids support medication adherence for Aboriginal and Torres Strait Islander peoples? An exploration of patients' perspectives, experiences and use on the North Coast of New South Wales.

INTRODUCTION: Management of medication regimens and improvement of medication-taking behaviours may require various levels of support, education, engagement and barrier reduction from health services and or pharmacists. The use of dose administration aids (DAAs) may improve medication management for some people, and therefore may facilitate positive health benefits. This Australian study was informed by a literature review that found there was a dearth of data about Aboriginal and Torres Strait Islander peoples' use of DAAs. This study therefore aimed to understand the experiences of Aboriginal and Torres Strait Islander people living on the North Coast of New South Wales with DAAs and if the provision of DAAs supported medication-taking behaviours. METHODS: A mixed-methods approach that included data collected from a questionnaire and a series of focus groups was used in this study. Analysis was completed at three stages throughout the study. RESULTS: A total of 30 Aboriginal participants participated in the study. Participants lived in the area ranging from Tweed Heads to Port Macquarie. Twenty-six participants completed the questionnaire and 20 participated in the focus groups; 16 completed both. Participants felt they were managing their medications well. The study noted that, despite this assessment, 45% of focus group participants (9/20) missed taking medications regularly for various reasons. The medication regimens of participants were varied and potentially complex; for example, some participants were taking up to 23 individual doses of oral medications and insulin injections daily as a part of these regimens. Participants described their use of DAAs and how they supported their medication-taking both functionally and financially. Most participants reported that DAAs helped them manage their medications. The weekly or fortnightly provision of DAAs provided regular opportunities for pharmacists to interact with patients and/or their caregivers, supporting improved therapeutic relationships and possibly better health outcomes. CONCLUSION: DAAs were an important tool for improving medication management for most study participants. DAAs provided affordable and appropriate in-home support for patients to follow prescribed medication regimens. For the participants from this small study who used DAAs and viewed them as an important tool for managing medications, removal of financial subsidies that assist the provision of DAAs to Aboriginal and Torres Strait Islander peoples would have a negative effect on their ability to access them. This in turn may affect their medication-taking behaviours, potentially negatively affecting their long-term health outcomes. Further study regarding the Aboriginal and Torres Strait Islander patient experience of the use of DAAs over a longer period tracking medication adherence, and for a larger cohort of Aboriginal and Torres Strait Islander people, would be beneficial to understanding experience of use of DAAs on a wider scale.

Women's reasons for taking complementary medicine products in pregnancy and lactation: Results from a national Australian survey.

BACKGROUND: and purpose: Pregnant and breastfeeding women commonly use complementary medicine products (CMPs), including dietary supplements and herbal medicines. This study investigated women's reasons for use. MATERIALS AND METHODS: A national, cross-sectional, online survey conducted between July-September 2019 investigated reasons for CMP use during pregnancy and lactation. Australian women who were currently pregnant and/or breastfeeding participated. Data analysis included descriptive statistics, Chi-square and principal component analyses. RESULTS: Of the 810 women surveyed (n = 354 pregnant; n = 456 breastfeeding), most reported prior CMP use and felt that CMPs had been beneficial to maintaining and optimising their own and their children's health. However, when ill, they preferred medicines prescribed by doctors or pharmacists. Perceived benefits to their unborn or breastfeeding babies' health and their own health (both cohorts), the health of their pregnancy (pregnant participants), and benefits to the breastfeeding process and breastmilk supply (breastfeeding participants) were important reasons for women's CMP use. CONCLUSION: Women's reasons for CMP use centred on perceived benefits to their own health and the health of their babies. Women's prior positive experiences with CMP use, combined with preferences for pharmaceutical use when ill, indicates their use of CMPs can be considered complementary, rather than alternative, to biomedical health care.

Scoping review - What do we know about Aboriginal peoples' use of dose administration aids?

ISSUE ADDRESSED: This paper aims to report findings of a scoping review which mapped and summarised available literature regarding Aboriginal peoples' use of Dose Administration Aids (DAAs) for improved medication management. Aboriginal and Torres Strait Islander peoples have higher rates of chronic disease than other Australians. This leads to increased numbers of prescribed medications and complex medication taking regimens. The Australian Government and Pharmacy Bodies provide programs for Aboriginal peoples with chronic conditions, including programs supporting access to DAAs to improve medication adherence. METHODS: The search strings used included three key concepts: Indigeneity; DAAs and outcomes. PubMed, Medline via Ovid and the grey literature were searched. RESULTS: After removal of duplicates, 426 papers were screened by title and abstract for inclusion. A further 407 papers were then excluded leaving a total of nineteen papers included in the review. Only three of these papers included all three concepts in the search criteria, and none of these were empirical studies. CONCLUSION: The lack of studies found in this review support the requirement for empirical research regarding the effects of DAAs on medication taking behaviours of Aboriginal people, and the programs that provide them. SO WHAT?: The Australian Government funds programs that provides access to DAAs as a method of improving medication taking behaviours. But what do we really know about DAAs and if or how they assist in this goal? This review scopes out what is known, in order to direct studies that will answer this question.

Demographics, health literacy and health locus of control beliefs of Australian women who take complementary medicine products during pregnancy and breastfeeding: A cross-sectional, online, national survey.

BACKGROUND: Pregnant and breastfeeding women's use of complementary medicine products (CMPs) is common, and possibly associated with autonomous health care behaviours. However, the health literacy levels and health locus of control (HLOC) beliefs of women who use CMPs in pregnancy and lactation have not been previously assessed in a large Australian sample. AIM: The aim of this study is to determine the health literacy levels and HLOC beliefs of women who use CMPs in pregnancy and lactation and determine the types of CMPs used. METHODS: A cross-sectional, national, online survey of Australian pregnant or breastfeeding women aged 18 years and older, and currently using CMPs was conducted. RESULTS: A total of 810 completed surveys (354 pregnant and 456 breastfeeding women) were analysed. Most had adequate functional health literacy levels (93.3%). Health care practitioners (HCPs) HLOC mean scores were the highest for the sample, followed by Internal HLOC beliefs mean scores. Almost all (n = 809) took at least one dietary supplement, the most popular being pregnancy and breastfeeding multivitamins, iron supplements and probiotics. Use was generally in line with clinical recommendations, except for low rates of iodine supplementation. Herbal medicine use was lower for the total sample (57.3%, n = 464), but significantly higher (p < .0001) for the breastfeeding cohort, with consumers taking one to four herbal medicines each. The most popular herbs were raspberry leaf, ginger, peppermint and chamomile (pregnant respondents) and chamomile, ginger and fenugreek (breastfeeding respondents). CONCLUSIONS: Respondents were health literate, with high scores for Internal and HCP HLOC scales, suggesting that they are likely to demonstrate self-efficacy, positive health behaviours and work well in partnership with HCPs. HCPs can facilitate discussions with pregnant and breastfeeding women using CMPs, while considering women's health literacy levels, health beliefs and goals.

Stigmatized for standing up for my child: A qualitative study of non-vaccinating parents in Australia.

BACKGROUND: Vaccine refusal is highly polarizing in Australia, producing a challenging social landscape for non-vaccinating parents. We sought to understand the lived experience of non-vaccinating parents in contemporary Australia. METHODS: We recruited a national sample of non-vaccinating parents of children <18 yrs, advertising on national radio, in playgrounds in low vaccination areas, and using snowballing. Grounded Theory methodology guided data collection (via semi-structured interviews). Inductive analysis identified stigmatization as a central concept; stigma theory was adopted as an analytical lens. RESULTS: Twenty-one parents from regional and urban locations in five states were interviewed. Parent's described experiences point to systematic stigmatization which can be characterized using Link & Phelan's five-step process. Parents experienced (1) labelling and (2) stereotyping, with many not identifying with the "anti-vaxxers" portrayed in the media and describing frustration at being labelled as such, believing they were defending their child from harm. Participants described (3) social "othering", leading to relationship loss and social isolation, and (4) status loss and discrimination, feeling "brushed off" as incompetent parents and discriminated against by medical professionals and other parents. Finally, (5) legislative changes exerted power over their circumstances, rendering them unable to provide their children with the same financial and educational opportunities as vaccinated children, often increasing their steadfastness in refusing vaccination. CONCLUSION: Non-vaccinating Australian parents feel stigmatized for defending their child from perceived risk of harm, reporting a range of social and psychological effects, as well as financial effects from policies which disadvantaged their children through differential financial treatment, and diminished early childhood educational opportunities. While it might be argued that social stigma and exclusionary policies directed a small minority for the greater good are justified, other more nuanced approaches based on better understandings of vaccine rejection could achieve comparable public health outcomes without the detrimental effect on unvaccinated families.

Early career midwives' perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments.

OBJECTIVE: The aim of this study was to investigate whether a specifically designed whole-ofdegree strategy utilising groupwork assessments was effective in facilitating the development of early career midwives' teamwork skills. DESIGN AND METHODS: A qualitative study using in-depth, semi-structured interviews was undertaken with early career midwives who had graduated within the previous two years. This study is the final cycle of a larger participatory action research project. Qualitative data was analysed using thematic analysis. PARTICIPANTS: Nineteen early career midwives from one Australian university participated. Their preregistration education was via a Bachelor of Midwifery. Their education included a whole-of-degree educational strategy to facilitate the development of teamwork skills. FINDINGS: One overarching theme "Becoming an Effective Team Member' and three sub-themes: 'Learning and developing Teamwork Skills'; 'More secure and confident' and 'Self-Assurance in interprofessional interactions' were identified in the interview data. Despite their junior status, the midwives demonstrated the knowledge, skills, and attitudes of an effective team member. Their social and emotional skills appeared well developed and they felt confident interacting with other health care workers in a professional manner. KEY CONCLUSIONS: Early career midwives who were taught and practiced teamwork skills throughout their degree, appear to have developed the social and emotional competencies required for effective teamwork. IMPLICATIONS FOR PRACTICE: The capacity for effective teamwork of this small group of early career midwives has the potential to improve the quality and safety of their care for childbearing women. Learning teamwork skills in the educational setting appears to have generated skills focused on conflict resolution, emotional self-regulation and social and emotional competency in these new midwives. These are favourable skills in the emotionallycharged environment of maternity care, where inter-collegial bullying is present and where new midwives can experience poor psychological wellbeing. Health care employers want new graduate health professionals to be work ready and to have the skills necessary to be effective team members. The program undertaken by these new graduates may be of assistance in developing these capabilities in other health students. THE KNOWN: Teamwork skills are an intrinsic part of the day-to-day activities of maternity services, influencing the workplace culture, retention of midwives and the quality and safety of care. Poor teamwork is associated with clinical errors, bullying and high turnover of staff. THE NEW: Early career midwives who were taught teamwork skills and practice these skills using their groupwork assignments throughout their undergraduate degree appear to demonstrate the social and emotional competencies required for effective teamwork. THE IMPLICATIONS: Implementing a whole-of-degree program to develop teamwork skills in undergraduate midwifery students may improve early career midwives' social and emotional competencies and interactions with other health professionals. Learning teamwork skills in the educational setting may generate skills in the new midwife that focus on conflict resolution, emotional self-regulation, and social and emotional competency. These are favourable skills in the emotionally charged environment of maternity care, where inter-collegial bullying is present and where new midwives can experience poor psychological wellbeing.

Midwifery care of non-vaccinating families - Insights from the Byron Shire.

PROBLEM: Midwives may feel ill-equipped to manage clinical encounters with non-vaccinating parents. BACKGROUND: Pregnancy is a peak time in the formation of parents' vaccination views and intention. Midwives are central to maternity care in Australia. While most midwives will have infrequent contact with families who intend not to vaccinate, when they do, they must feel equipped to communicate with them in a manner which fulfils their professional responsibilities, acknowledges parental autonomy and facilitates continued engagement. AIM: To understand how midwives can most effectively communicate with non-vaccinating parents. METHODS: We conducted in-depth interviews with 32 non-vaccinating parents and six key informant health professionals, and a focus group of six midwives. Data collection occurred in the Byron Shire of New South Wales, where childhood vaccination rates are persistently lower than national averages. FINDINGS: This study explores four central codes. The first, 'hold on…I'm not sure about this' providing insights into moments of doubt preceding parents' decisions not to vaccinate. The second 'Pregnancy: a decision-making focal point' reinforces the importance of effective vaccination recommendations in the antenatal period. 'Manipulation and ambivalence' examines why overzealous or unclear recommendations about vaccination are unhelpful, and the fourth central code 'engage, inform and encourage' summarise recommendations from health professionals who are experienced in communicating, apparently effectively, with non-vaccinating families. DISCUSSION: Insights from this study are used to recommend practical strategies which may be employed by midwives and maternity units to successfully and professionally manage clinical encounters with non-vaccinating parents. CONCLUSION: Midwives are well positioned to provide clear recommendations to parents regarding childhood vaccination whilst maintaining engagement and meeting the goals of woman-centred care.

Using Facebook to recruit to a national online survey investigating complementary medicine product use in pregnancy and lactation: A case study of method.

BACKGROUND: Online recruitment can be targeted efficiently to recruit specific samples for survey research. It has been shown to be a cost-effective method of recruitment, and useful for geographically dispersed populations. OBJECTIVES: To describe the use of Facebook to recruit a targeted sample of expectant and breastfeeding mothers to a national online survey. Different techniques to assess response rates using data provided by Facebook are also described. METHODS: Participants accessed an anonymous online survey through a link included in posts from a Facebook page specifically set up for the research. Recruitment strategies were primarily of two types. Firstly, Facebook was paid to promote posts by displaying them on potential participants' Facebook feeds. Secondly, by purposive and snowball recruitment through the sharing of posts on relevant Facebook pages. Post success was measured by the reach, impressions, link clicks, post clicks, and click through rates; and for boosted posts, the cost per day, and cost per engagement with the post as well. Traditional methods of calculating response rates, and response rates using post clicks and survey link clicks were calculated. RESULTS: After 10 weeks of recruitment, 1418 participants had enrolled in the study, and of these 810 (57.1%) completed the 20-minute (70 question) survey. Women participated from across Australia. Both paid and purposive approaches to promotion contributed to recruitment success. Paid promotions at higher costs for fewer days were the most successful. Total paid promotion costs were (Australian) $1147.97 (or $1.44 per completed survey). Purposive promotion was slower, but also contributed significantly to the number of people who saw the posts and clicked through to the survey. Traditional response rate calculations showed a response rate of 0.8%. Using post clicks and survey link clicks in calculations, resulted in response rates of 23.1% and 42.7%, respectively. CONCLUSIONS: A combination of paid promotions and purposive and snowball recruitment on Facebook were used to successfully recruit 1418 participants resulting in 810 completed surveys over a 10-week period, at a low cost per participant. Use of additional methods to measure response rates may be useful in measuring the success of using Facebook posts in recruitment.

Artspace: Enabling young women's recovery through visual arts: A qualitative study.

ISSUE ADDRESSED: This article reports the qualitative evaluation of "Artspace," an innovative clinical program combining creative arts with physical and mental health care for young women. The program, provided since 2004, comprises weekly visual arts sessions alongside a youth health clinic offering drop-in appointments with a nurse, GP and counsellor. METHODS: A qualitative evaluation of Artspace was conducted between 2016 and 2017. RESULTS: The evaluation showed that Artspace was particularly beneficial for those clients who had considerable exposure to social adversity and trauma, and were experiencing related serious health impacts. Artspace facilitated their recovery by enabling equitable access facilitation, social inclusion, creating a "holding" environment, and through the directly therapeutic benefits of artist-led arts processes. CONCLUSIONS: Our study highlights the positive impact of artist-led programs such as Artspace. It also attests to the importance of long-term sustainability of services, to allow the time needed for young people to experience genuine and sustained recovery, and to reduce the otherwise likely disadvantages associated with mental and physical health problems, as they move into their adult lives. SO WHAT?: Youth health researchers have been recommending arts programs at health services as a means of engaging young people in health care for over 15 years, however, it remains an underutilised approach in primary care settings. Our evaluation affirms the effectiveness of art programs for this, and also demonstrates that art programs can be a key contributor to recovery from the serious health impacts of adversity and trauma.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives in Jordan.

INTRODUCTION: Episiotomy is still performed routinely by clinicians in many countries. The aim of this study was to determine the knowledge of, attitudes towards and experience of episiotomy practice among clinicians working in public hospitals in Jordan. METHODS: A cross-sectional study, using a self-administered survey questionnaire, was conducted among midwives and obstetricians in three public hospitals in Jordan. RESULTS: 112 (87.5%) clinicians responded to the questionnaire. Low knowledge level of evidence about overuse and risk of episiotomy was identified among participants with a significant difference among obstetricians and midwives (P<0.05). Results revealed that both obstetricians and midwives have limited access to evidence which is not emphasised in their learning, practice, or hospital policy. The majority of obstetricians (80%) and midwives (79%) thought an episiotomy rate of 81% is about right. The most common reason for performing episiotomy identified by both obstetricians (83.1%) and midwives (75.5%) was to reduce the risk of 3rd and 4th degree perineal laceration. The most common obstacle to reducing episiotomy rate reported by obstetricians (78.0%) was lack of training on preventing perineal tears, while the most common obstacles reported by midwives were insufficient time to wait for the perineum to stretch (56.6%) and difficulty changing the conventional practices in the labour ward (52.8%). CONCLUSION: This study identifies that obstetricians and midwives in Jordan rely on non evidence-based beliefs to guide their practice on performing an episiotomy. Training, continuing education, and developing evidence based clinical policies and guidelines for surgical procedures, such as in an episiotomy, are needed.

Factors influencing women's decision-making regarding complementary medicine product use in pregnancy and lactation.

BACKGROUND: The prevalence of complementary medicine product (CMP) use by pregnant or breastfeeding Australian mothers is high, however, there is limited data on factors influencing women's decision-making to use CMPs. This study explored and described the factors influencing women's decisions take a CMP when pregnant or breastfeeding. METHODS: Qualitative in-depth interviews and focus group discussions were held with 25 pregnant and/or breastfeeding women who currently used CMPs. Participants' health literacy was assessed using a validated single-item health literacy screening question and the Newest Vital Sign. Interview and focus group discussions were audio-recorded, transcribed verbatim and thematically analysed. RESULTS: Participants were a homogenous group. Most had higher education, medium to high incomes and high health literacy skills. They actively sought information from multiple sources and used a reiterative collation and assessment process. Their decision-making to take or not to take CMPs was informed by the need to establish the safety of the CMPs, as well as possible benefits or harms to their baby's or their own health that could result from taking a CMP. Their specific information needs included the desire to access comprehensive, consistent, clear, easy to understand, and evidence-based information. Women preferred to access information from reputable sources, namely, their trusted health care practitioners, and information linked to government or hospital websites and published research. A lack of comprehensive, clear, consistent, or evidence-based information often led to decisions not to take a CMP, as they felt unable to adequately establish its safety or benefits. Conversely, when the participants felt the CMPs information they collected was good quality and from reputable sources, it reassured them of the safety of the CMP in pregnancy and/or breastfeeding. If this confirmed a clear benefit to their baby or themselves, they were more likely to decide to take a CMP. CONCLUSIONS: The participants' demographic profile confirms previous research concerning Australian women who use CMPs during pregnancy and lactation. Participants' high health literacy skills led them to engage in a reiterative, information-seeking and analysis process fuelled by the need to find clear information before making the decision to take, or not to take, a CMP.

Complementary medicine products information-seeking by pregnant and breastfeeding women in Australia.

OBJECTIVE: Complementary medicine product use in pregnancy and lactation is common but little is known about women's health literacy and information-seeking regarding this. The objectives of this study were to identify and explore pregnant or breastfeeding women's sources of, and rationale for seeking complementary medicine products information, the types of information sought, and how women felt their health care practitioners can help them receive information that meets their needs. DESIGN: A qualitative research design consisting of in-depth interviews and focus group discussions was conducted. Data were thematically analysed. Participants also completed two validated health literacy screening tools. SETTING: Communities in regional and metropolitan settings in Sydney and Northern New South Wales, and South-East Queensland, Australia. PARTICIPANTS: Twenty-five women (n = 7 pregnant, n = 17 breastfeeding, n = 1 both pregnant and breastfeeding) who currently used complementary medicine products participated. Eleven women were pregnant with or breastfeeding their first child; 14 had between one and four older children. FINDINGS: Twenty-four participants had high health literacy according to the validated screening tools. Around half of the participants had used complementary medicine products for most of their lives and 17 had used complementary medicine products to resolve or manage complex health conditions in adulthood or childhood. Women sought complementary medicine products information from three main sources. 1) Practical and safety information on complementary medicine products was sought from health care practitioners and published research; 2) health care practitioners were also sources of information on reasons for complementary medicine products recommendations and physiological actions; and 3) sharing experiences of complementary medicine products use with other mothers appeared to help women understand what to expect when taking complementary medicine products, support social-emotional wellbeing and encourage participants to look after their own health. Participants strongly expressed the desire for their mainstream biomedical health care practitioners to be more informed in, and open to, complementary medicine product use in pregnancy and breastfeeding. KEY CONCLUSIONS: Participants' high health literacy skills may have influenced them to seek comprehensive information on complementary medicine products from a variety of professional and lay sources. Their use of complementary medicine products in pregnancy and breastfeeding was a natural consequence from previous positive experiences with complementary medicine products and/or therapies. IMPLICATIONS FOR PRACTICE: Maternity care practitioners can positively enhance their interactions with pregnant or breastfeeding women who use complementary medicine products by respectfully discussing use within the context of these women's values and health goals, and by furthering their own education in complementary medicine products' safety, efficacy and indications in pregnancy and breastfeeding.

Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE Framework.

BACKGROUND: Birthing on Country is an international movement to return maternity services to First Nations communities and community control for improved health and wellbeing. QUESTION: How can we implement Birthing on Country services for Aboriginal and/or Torres Strait Islander families across Australia? METHODS: We have developed a framework from theoretical, policy and research literature on Birthing on Country; Aboriginal and Torres Strait Islander voices from across Australia; reviews exploring programs that have improved outcomes for Indigenous mothers and infants; and the retrospective synthesis of learnings from two empirical studies that have redesigned maternal infant health services and improved outcomes for Aboriginal and Torres Strait Islander families. RESULTS: The RISE Framework has four pillars to drive important reform: (1) Redesign the health service; (2) Invest in the workforce; (3) Strengthen families; and, (4) Embed Aboriginal and/or Torres Strait Islander community governance and control. We present the evidence base for each pillar and practical examples of moving from the standard 'western' model of maternity care towards Birthing on Country services. CONCLUSIONS: Application of the RISE framework to plan, develop and monitor Birthing on Country services is likely to result in short and long-term health gains for Aboriginal and Torres Strait Islander families.

Understanding non-vaccinating parents' views to inform and improve clinical encounters: a qualitative study in an Australian community.

OBJECTIVES: To explain vaccination refusal in a sample of Australian parents. DESIGN: Qualitative design, purposive sampling in a defined population. SETTING: A geographically bounded community of approximately 30 000 people in regional Australia with high prevalence of vaccination refusal. PARTICIPANTS: Semi structured interviews with 32 non-vaccinating parents: 9 fathers, 22 mothers and 1 pregnant woman. Purposive sampling of parents who had decided to discontinue or decline all vaccinations for their children. Recruitment via local advertising then snowballing. RESULTS: Thematic analysis focused on explaining decision-making pathways of parents who refuse vaccination. Common patterns in parents' accounts included: perceived deterioration in health in Western societies; a personal experience introducing doubt about vaccine safety; concerns regarding consent; varied encounters with health professionals (dismissive, hindering and helpful); a quest for 'the real truth'; reactance to system inflexibilities and ongoing risk assessment. CONCLUSIONS: We suggest responses tailored to the perspectives of non-vaccinating parents to assist professionals in understanding and maintaining empathic clinical relationships with this important patient group.

Women's health literacy and the complex decision-making process to use complementary medicine products in pregnancy and lactation.

BACKGROUND: Little is known about women's decision-making processes regarding using complementary medicine products (CMPs) during pregnancy or lactation. OBJECTIVES: To explore the decision-making processes of women choosing to use CMPs in pregnancy and lactation; and to investigate how women's health literacy influences their decisions. DESIGN, SETTING AND PARTICIPANTS: In-depth interviews and focus group discussions were held with twenty-five pregnant and/or breastfeeding women. Data were analysed using thematic analysis. RESULTS: Key to women's decision making was the desire to establish a CMPs safety and to receive information from a trustworthy source, preferably their most trusted health-care practitioner. Women wanted positive therapeutic relationships with health-care practitioners and to be highly involved in the decisions they made for the health of themselves and their children. Two overarching components of the decision-making process were identified: (a) women's information needs and (b) a preference for CMP use. Women collated and assessed information from other health-care practitioners, other mothers and published research during their decision-making processes. They showed a strong preference for CMP use to support their pregnancy and breastfeeding health, and that of their unborn and breastfeeding babies. DISCUSSION AND CONCLUSIONS: Complex decision-making processes to use CMPs in pregnancy and lactation were identified. The participants showed high levels of communicative and critical health literacy skills in their decision-making processes. These skills supported women's complex decision-making processes.

Caring behaviours by midwives: Jordanian women's perceptions during childbirth.

BACKGROUND: It is agreed internationally that caring is a central part of nursing and midwifery. There is a growing concern about the lack of caring in childbirth settings in developing countries including Jordan. The aim of this study was to explore women's perceptions of midwives' caring behaviours during childbirth to assist develop strategies for improvement. METHODS: An exploratory and qualitative design utilizing semi-structured interviews was used to explore women's perceptions of midwives' caring behaviours during childbirth. Interviews were digitally recorded and transcribed verbatim. Data were analysed by using thematic coding. Repetitive themes that described commonalties between the women's perceptions were identified and described. FINDINGS: Twenty-one women participated in the interviews. Three main themes were identified: (1) Women's feelings during childbirth: they felt frightened, humiliated, ignored, and disrespected. Negative actions in term of tangible or physical non-caring behaviours and emotional behaviours were reported. (2) Women's perceptions of the caring behaviours of midwives during childbirth: women had negative experiences during childbirth, they reported disrespectful manners and physical and empathetic abandonment by midwives during childbirth. (3) Women's preferred caring behaviours: women wanted the midwives to listen to what they say, to demonstrate respect for them, and be truly 'present' for women when they needed them. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The absence of caring behaviours from a group of Jordanian midwives' elicited negative responses from women in labour, who found this distressing. Devising strategies, informed by the study, focused on the preferred caring behaviours identified by women, could improve the standard of care provided by midwives currently working in labour wards in public hospitals in Jordan. These strategies should recognise that core competencies for midwifery care must go beyond skills training alone and highlight the importance of the psychosocial and emotional components of caring as well as routine procedural activities.

Complementary medicine products: Information sources, perceived benefits and maternal health literacy.

BACKGROUND: Maternal health literacy plays an important role in women's decisions regarding health care during pregnancy and lactation. This systematic review aimed to investigate the use of complementary medicine products by pregnant and breastfeeding women; information sources accessed, and the role health literacy plays in women's use of complementary medicine products. METHODS: Seven databases were searched for peer-reviewed quantitative or mixed- methods studies (1995-2017). Thematic analysis identified key themes regarding women's use of complementary medicine products for perceived benefits to the mother, pregnancy, baby and/or breastfeeding process. RESULTS: 4574 papers were identified; 56 met the inclusion criteria. Most (n=53) focused on the use of complementary medicine products during pregnancy; six focused on use in lactation. Herbal medicines were the main complementary medicine product type discussed (n=46) for both pregnancy and breastfeeding. Women perceived complementary medicine products to be beneficial in supporting their own pre and postnatal health, their pregnancies, growing foetuses, labour and birth, and/or breastfeeding. Health care professionals, followed by other interpersonal relationships and the media were the most commonly reported information sources accessed. An interactive model of health literacy revealed that information sources within a woman's health literacy environment, combined with other information sources, influenced her decision making regarding complementary medicine product use. CONCLUSIONS: Pregnant and breastfeeding women use complementary medicine products for various self-perceived benefits related to their own, unborn or breastfeeding babies' health. Examining these with reference to an interactive health literacy model helps identify the decision-making process mothers undergo when choosing to use complementary medicine products.

Alliances and evidence: Building the capacity and effectiveness of rural health advocacy in Australia.

This article describes two strategies that have strengthened the capacity and effectiveness of rural health advocacy in Australia over the past nearly three decades. The first is the development of the National Rural Health Alliance, an organisation that grew from strategic efforts to develop relationships between rural and remote health practitioners and organisations. The second is the development, organisation and use of data and evidence to highlight rural health needs. There has been important synergy between these two streams of activity, with research and evidence providing the tools and the National Rural Health Alliance providing the strategy and techniques to influence the rural and remote health care agenda.

Complementary medicine products used in pregnancy and lactation and an examination of the information sources accessed pertaining to maternal health literacy: a systematic review of qualitative studies.

BACKGROUND: The prevalence of complementary medicine use in pregnancy and lactation has been increasingly noted internationally. This systematic review aimed to determine the complementary medicine products (CMPs) used in pregnancy and/or lactation for the benefit of the mother, the pregnancy, child and/or the breastfeeding process. Additionally, it aimed to explore the resources women used, and to examine the role of maternal health literacy in this process. METHODS: Seven databases were comprehensively searched to identify studies published in peer-reviewed journals (1995-2017). Relevant data were extracted and thematic analysis undertaken to identify key themes related to the review objectives. RESULTS: A total of 4574 articles were identified; 28 qualitative studies met the inclusion criteria. Quantitative studies were removed for a separate, concurrent review. Herbal medicines were the main CMPs identified (n = 21 papers) in the qualitative studies, with a smaller number examining vitamin and mineral supplements together with herbal medicines (n = 3), and micronutrient supplements (n = 3). Shared cultural knowledge and traditions, followed by women elders and health care professionals were the information sources most accessed by women when choosing to use CMPs. Women used CMPs for perceived physical, mental-emotional, spiritual and cultural benefits for their pregnancies, their own health, the health of their unborn or breastfeeding babies, and/or the breastfeeding process. Two over-arching motives were identified: 1) to protect themselves or their babies from adverse events; 2) to facilitate the normal physiological processes of pregnancy, birth and lactation. Decisions to use CMPs were made within the context of their own cultures, reflected in the locus of control regarding decision-making in pregnancy and lactation, and in the health literacy environment. Medical pluralism was very common and women navigated through and between different health care services and systems throughout their pregnancies and breastfeeding journeys. CONCLUSIONS: Pregnant and breastfeeding women use herbal medicines and micronutrient supplements for a variety of perceived benefits to their babies' and their own holistic health. Women access a range of CMP-related information sources with shared cultural knowledge and women elders the most frequently accessed sources, followed by HCPs. Culture influences maternal health literacy and thus women's health care choices including CMP use.