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Introduction: Mothers’ participation in the care of their sick newborns in newborn care units (NCUs) has been linked to several advantages including earlier discharge, fewer complications, better mother-baby bonding, and an easier transition after discharge. This study aimed to understand mothers' experiences while participating in the care of their sick newborns in the NCUs to inform interventions promoting mothers’ participation in resource-limited settings. Methods: We conducted an exploratory qualitative study comprised of 18 in-depth interviews with mothers caring for their newborns in two NCUs at a regional referral and general hospital in Eastern Uganda between April and May 2022. The interviews were audio-recorded and then transcribed. For analysis, we used a thematic approach. Results: Mothers participated in activities ranging from the more basic, like breastfeeding and skin-to-skin care, to the more “clinical”, including tasks such as nasal gastric feeding, and oxygen therapy provision. Mothers were eager to participate in care. The fear of losing their baby was a major underlying sentiment driving their participation. Mothers' perspectives on i) medical care, ii) the living space in the NCU, and iii) their support system emerged as key themes. Mothers expressed varying degrees of confidence in care, depending on whether or not their baby was improving. Although some mothers needed medical attention, NCU staff only paid attention to the baby. NCU space was crowded, and mothers expressed a lack of control over their personal space. Mothers turned to families to mobilize resources because caring for babies was logistically and financially taxing. Family member support roles and expectation were gendered. Conclusion: This study indicates that mothers are eager to participate in their babies' care in the NCU. Many negative experiences, however, taint mothers' participation in their babies' care. Interventions to encourage mothers' participation in the NICU should focus on improving NCU staff-mother interaction, privacy, and space issues, and leveraging the family's role in supporting mothers.

IntroductionHealth information management system data is collected for national planning and evaluation but rarely used for health care improvements at the sub-national or facility-level in low-and-middle-income countries. Research suggests that perceived data quality and lack of feedback are contributing factors. We aimed to understand maternity care providers’ perceptions of data and how they use them, with a view to co-design interventions to improve data quality and use.MethodsWe based our research on constructivist grounded theory. We conducted 14 in-depth interviews, two focus group discussions with maternity care providers and 48 hours of observations in maternity wards of two rural hospitals in Southern Tanzania. Constant comparative data analysis was applied to develop initial and focused codes, sub-categories and categories continuously validated through peer and member checks.ResultsMaternity care providers appropriated numeric data on service provision to reconcile their professional values and demands from managers and the community with effects of a challenging working environment. They felt controlled by their managers’ data requirements and alienated from service provision data. Providers added informal documentation ways for their own narrative data needs to reflect on and improve service quality. These also assisted them to recreate social relationships with managers, clients and the community. The resulting documentation system led to duplication and increased systemic complexity.ConclusionsData from health information systems does not represent an independent and neutral entity but is embedded into the social realities of different users. Appropriation and use of data reflect these realities and users’ working environment. Interventions to improve data quality and use may need to incorporate the multitude of clinical and administrative documentation and data needs to avoid duplication and inefficiencies.

Background The EQ-5D-5L, the EQ VAS, and the time trade-off (TTO) are commonly used to report and value health. Still, there is a need to better understand how these questionnaires and methods are perceived by the respondents, as well as the thoughts and motives behind their responses. The aim of this study was to increase knowledge of how individuals think and reason when reporting and valuing their own current health, using EQ-5D-5L, EQ VAS, and an open-ended TTO question. Methods Twenty patients with type 1 diabetes participated in qualitative individual think aloud interviews in Stockholm, Sweden. Participants were asked to describe their thoughts when responding to three assessments. The interviews were transcribed verbatim and analyzed using thematic analysis. Results The analysis showed that participants conducted the assessments by contextualizing and interpreting instructions, relating the questions to their own health, using different recall periods and time perspectives, and using personal, interpersonal, or normative comparators. It was challenging to reduce the experience of everyday life into a response option, and the thoughts behind the responses differed between the assessments. Before deciding on what to include, participants thought of the purpose and context of the assessments. Current health or past experiences of health were applied in the EQ-5D descriptive system and in EQ VAS, while participants focused on the future in the TTO. Thoughts about the impact on others, personal goals, and expectations on future health were more clearly integrated in the TTO assessment. All participants considered the trade-off between life years and health. However, despite the use of different comparators, the concept of ‘full health’ was found difficult to imagine or relate to. Conclusions This study provides insights as to how responses to the EQ-5D-5L, EQ VAS, and TTO assessments are complementary and where these assessments differ in adults with a chronic condition. The findings may contribute to a better understanding when interpreting the quantitative results and contribute to the literature pertaining to possible explanations for differences in health state values depending on the valuation method.

Objective:To map and characterise the interactions between the food environment and immigrant populations from low- and middle-income countries living in high-income countries.Design:A scoping review was carried out following the framework outlined by Arksey and O’Malley, as well as Levac et al. Peer-reviewed studies in English published between 2007 and 2021 were included. Two reviewers screened and selected the papers according to predefined inclusion criteria and reporting of results follows the PRISMA-ScR guidelines. A ‘Best fit’ framework synthesis was carried out using the Analysis Grid for Environments Linked to Obesity (ANGELO) framework.Setting:High-income countries.Participants:Immigrants from low- and middle-income countries.Results:A total of sixty-eight articles were included, primarily based in the USA, as well as Canada, Australia and Europe, with immigrants originating from five regions of the globe. The analysis identified three overarching themes that interconnected different aspects of the food environment in addition to the four themes of the ANGELO framework. They demonstrate that in valuing fresh, healthy and traditional foods, immigrants were compelled to surpass barriers in order to acquire these, though children’s demands, low incomes, time scarcity and mobility influenced the healthiness of the foods acquired.Conclusion:This study brought together evidence on interactions between immigrant populations and the food environment. Immigrants attempted to access fresh, traditional, healthier food, though they faced structural and family-level barriers that impacted the healthiness of the food they acquired. Understanding the food environment and interactions therein is key to proposing interventions and policies that can potentially impact the most vulnerable.

ObjectivesIn many resource-limited health systems, point-of-care tests (POCTs) are the only means for clinical patient sample analyses. However, the speed and simplicity of POCTs also makes their use appealing to clinicians in high-income countries (HICs), despite their having greater laboratory accessibility. Although also part of the clinical routine in HICs, the utility of POCTs is relatively unknown in such settings as compared to others.In a Swedish paediatric emergency department (PED) where POCT use is routine, we aimed to characterize health care providers’ perspectives on the clinical utility of POCTs and explore their implementation in the local setting; to compare such experiences to those reported in other settings; and finally, to gather requests for ideal novel POCTs.DesignQualitative study using focus group discussions. A data-driven content analysis approach was used for analysis.SettingThe PED of a secondary paediatric hospital in Stockholm, Sweden.ParticipantsTwenty-four health care providers clinically active at the PED were enrolled in six focus groups.ResultsA range of POCTs was routinely used. The emerging themeUtility of POCTs is double-edgedillustrated the perceived utility of POCTs. While POCT services were considered to have clinical and social value, the local testing practice was named to distract from the care for patients. Requests were made for novel POCTs and their implementation.ConclusionDespite their clinical integration, deficient implementation routines limit the benefits of POCT services to this well-resourced paediatric clinic. As such deficiencies are shared with other settings, it is suggested that some characteristics of POCTs and of their utility are less related to resource level and more to policy deficiency. To address this, we propose the appointment of skilled laboratory personnel as ambassadors to hospital clinics offering POCT services, to ensure higher utility of such services.ARTICLE SUMMARYStrengths and limitations of this studyThis is the first study to present the use and utility of POCTs in a HIC paediatric hospital setting, directly from the perspective of its clinical staff.Our main finding is that deficient implementation routines limit benefit of POCT services in this well-resourced setting, strongly indicating that such deficiencies are irrespective of resource level, and more related to policy deficiency.The findings of the relatively small study size may be contextual, yet we believe our main conclusions to be generalizable as most of our findings are compatible with those reported in other settings.The study is strengthened by the diversity of its participants, corresponding to the multi-professional staffing of the PED.

Self-management support and lifestyle interventions with an empowerment approach have been found to be effective strategies for health improvement among people at risk for or living with type 2 diabetes. Telephone coaching seems particularly efficient for individuals with low socioeconomic status and culturally and linguistically diverse backgrounds. In this mixed methods study, we investigate a telephone-delivered health coaching intervention provided by the diabetes project SMART2D (Self-Management Approach and Reciprocal learning for Type 2 Diabetes) implemented in socioeconomically disadvantaged areas in Stockholm, Sweden. We focus on the interaction between participants and facilitators as part of intervention fidelity. Recorded coaching sessions were scored using an interaction tool and analyzed by exploratory factor analysis and recorded supervisory discussions with facilitators analyzed using thematic analysis. The quantitative analysis showed that the intervention components were delivered as intended, however, differences between facilitators were found. The qualitative data highlighted differences between facilitators in the delivery, especially in relation to dietary and physical activity goalsetting. The level of language skills hindered the delivery flow and the tailoring of sessions to participants’ needs led to different delivery styles. The interaction between facilitators and participants is an important aspect of intervention implementation. Tailoring of interventions is necessary, and language-skilled facilitators are needed to minimize barriers in intervention delivery.

Background Understanding motivational determinants of physical activity (PA) is essential to guide the implementation of PA at individual and population level. Knowledge about the cross-cultural generalizability of these determinants is lacking and they have mostly been studied as separate factors. This study compares a motivational process model across samples from diverse populations with, or at risk of diabetes. Methods Measurement invariance of barrier identified regulation, barrier self-efficacy and social support was assessed in a rural Ugandan sample (n = 712) and disadvantaged samples with high proportions of immigrants in urban South Africa (n = 566) and Sweden (n = 147). These motivational determinants were then compared through multigroup structural equation modeling. Results The studied motivational constructs showed scalar invariance. Latent mean levels of perceived social support and barrier self-efficacy were lower in South Africa and Sweden. Structural models (for different PA outcomes) were not consistent across settings except for the association between perceived social support and identified regulation. Identified regulation was only associated with vigorous PA in Uganda and with moderate PA in South Africa. The association between social support and PA outcomes ranged from weak to not significant and the association between self-efficacy and PA was not significant. Self-reported PA was highest in Uganda and lowest in Sweden. Self-reported vigorous PA was significantly related to lower hemoglobin A1c levels, while moderate PA was not. Conclusions Findings suggest that: 1) it is feasible to compare a motivational process model across diverse settings; 2) there is lower perceived social support and self-efficacy in the urban, migrant samples; 3) identified regulation is a more promising determinant of PA than self-efficacy or social support in these populations; 4) associations between motivational determinants and PA depend on the perceived type and/or intensity of PA; 5) perceived relatedness functions as a basic psychological need across diverse settings; and 6) people’s perception of the PA they perform depends on their perceived level of intensity of PA which would have major implications for health promotion.

Background Recreational and sexual drug use among men who have sex with men may result in increased risk of poor health. The aim of this study was to better understand drug use and harm reduction techniques among Swedish men who have sex with men traveling to Berlin in order to improve the health of this population and inform public health strategies. Methods A qualitative study based on semi-structured interviews with 15 Swedish men aged 23–44 with experience of drug use were recruited through network sampling. Interviews were conducted in Stockholm and Berlin and analysed using content analysis. The interview guide included questions on drug use, context, health and safety. Results The participants engaged in drug use in both settings and in various contexts. Participants saw themselves as capable of finding a balance between pleasure, safety and risk with the aim to maximize positive effects while minimizing negative ones. The different risks of drug use were known, and participants relied on knowledge, harm reduction strategies and self-defined rules of intake to stay safe and healthy in a broad sense, both short term (i.e. during each session) and long term. Choice of drug and, frequency of intake, multi-use, risk of overdose, risk of HIV, purpose and context of use, how often, etc. were all part of the overall strategy. Knowledge of these methods was spread within the community and on-line rather than from counsellors or other health care providers. However, it did not always translate perfectly into practice and some had experienced overdoses and problematic use. Conclusions The findings of this study point to the need for increased adoption of harm reduction techniques in this population focusing on mitigating harm and prevention of risk of problematic use or starting injection drugs. Existing traditional services require adaptations to become more accessible and acceptable to sub-groups of drug users, including low-threshold services providing non-judgemental, evidence-based information. This will require funding of alternative providers such as STI/HIV clinics, among others, and health care providers to increase adoption of prevention strategies, specifically pre-exposure prophylaxis for HIV.

Work-related stress is a global problem causing suffering and economic costs. In Sweden, employees in human service occupations are overrepresented among persons on sick leave due to mental health problems such as stress-related disorders. The psychosocial work environment is one contributing factor for this problem, making it urgent to identify effective methods to decrease stress at the workplace. The aim of the study is to evaluate a participatory intervention to improve the psychosocial work environment and mental health using an embedded mixed methods design. The study is a controlled trial with a parallel process evaluation exploring fidelity and participants’ reactions to the intervention activities, experiences of learning and changes in behaviours and work routines. We collected data through documentation, interviews and three waves of questionnaires. Our results show small changes in behaviours and work routines and no positive effects of the intervention on the psychosocial work environment nor health outcomes. One explanation is end-users’ perceived lack of involvement over the process causing the intervention to be seen as a burden. Another explanation is that the intervention activities were perceived targeting the wrong organisational level. A representative participation over both content and process can be an effective strategy to change psychosocial working conditions and mental health.

Introduction In public health emergencies, local media are important sources of information for the public. Not much is known about the professional and personal roles and experiences of Sierra Leonean journalists during the Ebola virus disease (EVD) outbreak between 2014–2015. Methods/Principal findings This qualitative study is based on semi-structured interviews with 13 Sierra Leonean journalists based in urban Freetown and rural Waterloo in February and March 2016. The majority of the journalists worked for radio stations. The mostly male journalists represented national, regional and local radio stations. Transcripts of the interviews were analysed using thematic analysis. The analysis was inspired by previously reported journalist roles and agenda-setting theory, which state that the media filter what is happening, making a few core issues more salient. Sierra Leonean journalists shifted from being sceptical monitors in the beginning of the outbreak, to collaborative instructors towards the end. While they adapted to different roles, journalists struggled with their own fears for the virus, which hampered their work. They indicated that the training they received about Ebola helped them overcome their fear. Being trained gave a sense of security that helped them carry out their jobs. By turning into instructors, journalists stepped away from their journalistic professional detachment–potentially exacerbated by their personal experiences. Conclusion/Significance The first months of the outbreak were marked by passive agenda-setting roles of Sierra Leonean journalists. It took several months before the outbreak became a core issue in local media. In health emergencies, efforts should be made to partner with local media to use their platforms for local, trusted journalists and leaders to disseminate public health messages. Whereas this might hamper journalists’ credibility and can be challenging in areas with problematic press freedom, Sierra Leonean journalists experienced the outbreak as a driver of necessary change in their profession., Author summary Local media are important sources of information for the public during a health emergency. However, not much is known about the roles and experiences of local journalists who have to report under extraordinary circumstances. In this qualitative study, we interviewed Sierra Leonean journalists who reported during the 2014–2015 Ebola outbreak. The thematic analysis shows that the journalists adapted different roles over the course of the outbreak. They went from being sceptical about the existence of an outbreak at the start to changing into instructors at the end of the outbreak. Journalists struggled with their own fear for the virus, which they could overcome through targeted training, that helped them identify safe practices of reporting in the field. Our results show that it is possible to effectively partner with local media to disseminate public health messages. This might be challenging in settings with problematic press freedom, but Sierra Leonean journalists actually felt that the outbreak helped improve their practices.

Type 2 diabetes (T2D) and its complications are increasing rapidly in low- and middle-income countries, as well as among socioeconomically disadvantaged populations in high-income countries. Support for healthy lifestyle and self-management is paramount but not well implemented in health systems, and there is need for knowledge on how to design and implement interventions that are contextualized and patient centered and address special needs of disadvantaged population groups. The SMART2D project implements and evaluates a lifestyle and self-management intervention for participants recently diagnosed with or being at increased risk for T2D in rural communities in Uganda, an urban township in South Africa, and socioeconomically disadvantaged urban communities in Sweden. Our aim was to develop an intervention with shared key functions and a good fit with the local context, needs, and resources. The intervention program design was conducted in three steps facilitated by a coordinating team: (a) situational analysis based on the SMART2D Self-Management Framework and definition of intervention objectives and core strategies; (b) designing generic tools for the strategies; and (c) contextual translation of the generic tools and their delivery. This article focuses on community strategies to strengthen support from the social and physical environment and to link health care and community support. Situational analyses showed that objectives and key functions addressing mediators from the SMART2D framework could be shared. Generic tools ensured retaining of functions, while content and delivery were highly contextualized. Phased, collaborative approach and theoretical framework ensured that key functions were not lost in contextualization, also allowing for cross-comparison despite flexibility with other aspects of the intervention between the sites. The trial registration number of this study is ISRCTN11913581.

Introduction Communication is considered a key skill for physicians globally and has formed a central part of medical curricula since the WHO identified it as a key attribute of the ‘5-star doctor’. Communication of poor prognosis to patients and caregivers is particularly challenging, yet an important example of physicians’ clinical communication, and a priority within palliative care research. Knowledge is scarce regarding the different positions physicians adopt during poor prognosis communication, especially in sub-Saharan countries. Methods This qualitative study took place at the Cape Coast Teaching Hospital in Ghana’s Central Region. Physicians in the internal medicine department, with experience in communicating poor prognosis to patients and families on a weekly basis were purposively sampled. Based on the concept of information power, a maximum variation of participants, in terms of age, sex, seniority and experience was achieved after conducting 10 semistructured interviews in March 2019. Positioning theory was used as a theoretical lens to inform study design. The data were analysed through a constructivist thematic analysis approach. Results Physicians adopted six positions, considered as six different themes, during their communication of poor prognosis: clinical expert, educator, counsellor, communicator, protector and mentor. Physicians’ choice of position was fluid, guided by local context and wider health system factors. Physicians’ desire to communicate with patients and families in a way that met their needs highlighted three key challenges for communication of poor prognosis: linguistic difficulties, pluralistic health beliefs and the role of family. These challenges presented ethical complexities in relation to autonomy and non-maleficence. Conclusion Context is key to physicians’ communication of poor prognosis. Communication of poor prognosis is multifaceted, complex and unpredictable. Physicians’ communication training should be developed to emphasise contextual circumstances and physician support, and international policy models on physicians’ roles developed to include a greater focus on social accountability.

ObjectiveHealth system resilience can increase a system’s ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods.DesignA qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework.SettingPublic sector healthcare facilities and health departments in two districts exposed to flooding.ParticipantsTwenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding.ResultsThe theme ‘Collaboration across the system creates adaptability in the response’ reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response.ConclusionThe capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience.

Introduction Resilient health systems have the capacity to continue providing health services to meet the community’s diverse health needs following floods. This capacity is related to how the community manages its own health needs and the community and health system’s joined capacities for resilience. Yet little is known about how community participation influences health systems resilience. The purpose of this study was to understand how community management of pregnancy and childbirth care during floods is contributing to the system’s capacity to absorb, adapt or transform as viewed through a framework on health systems resilience. Methods Eight focus group discussions and 17 semi-structured interviews were conducted with community members and leaders who experienced pregnancy or childbirth during recent flooding in rural Cambodia. The data were analysed by thematic analysis and discussed in relation to the resilience framework. Results The theme ‘Responsible for the status quo’ reflected the community’s responsibility to find ways to manage pregnancy and childbirth care, when neither the expectations of the health system nor the available benefits changed during floods. The theme was informed by notions on: i) developmental changes, the unpredictable nature of floods and limited support for managing care, ii) how information promoted by the public health system led to a limited decision-making space for pregnancy and childbirth care, iii) a desire for security during floods that outweighed mistrust in the public health system and iv) the limits to the coping strategies that the community prepared in case of flooding. Conclusions The community mainly employed absorptive strategies to manage their care during floods, relieving the burden on the health system, yet restricted support and decision-making may risk their capacity. Further involvement in decision-making for care could help improve the health system’s resilience by creating room for the community to adapt and transform when experiencing floods.

The burden of type 2 diabetes is increasing rapidly, not least in Sub-Saharan Africa, and disadvantaged populations are disproportionally affected. Self-management is a key strategy for people at risk of or with type 2 diabetes, but implementation is a challenge. The objective of this study is to assess the determinants of self-management from an implementation perspective in three settings: two rural districts in Uganda, an urban township in South Africa, and socio-economically disadvantaged suburbs in Sweden. Data collection followed an exploratory multiple-case study design, integrating data from interviews, focus group discussions, and observations. Data collection and analysis were guided by a contextualized version of a transdisciplinary framework for self-management. Findings indicate that people at risk of or with type 2 diabetes are aware of major self-management strategies, but fail to integrate these into their daily lives. Depending on the setting, opportunities to facilitate implementation of self-management include: improving patient-provider interaction, improving health service delivery, and encouraging community initiatives supporting self-management. Modification of the physical environment (e.g. accessibility to healthy food) and the socio-cultural environment (i.e. norms, values, attitudes, and social support) may have an important influence on people's lifestyle. Regarding the study methodology, we learned that this innovative approach can lead to a comprehensive analysis of self-management determinants across different settings. An important barrier was the difficult contextualization of concepts like perceived autonomy and self-efficacy. Intervention studies are needed to confirm whether the pathways suggested by this study are valid and to test the proposed opportunities for change.

Introduction Due to the wide variety of definitions for critical illness, it is hard to define and estimate the burden of critically ill patients internationally. To be able to academically discuss both implementations and improvements, one needs to stand on a common ground on what the definition of critical illness is. Method Arksey and O’Malley’s scoping review methodology and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) will guide the conduct of this scoping review. We will search electronic databases PubMed, Web of Science and publication lists from Association of Anaesthetists of Great Britain and Ireland, The Scandinavian Society of Anaesthesiology and Intensive Care Medicine, European Society of Intensive Care Medicine, World Federation of Societies of Intensive and Critical Care Medicine will be hand searched to identify appropriate studies for inclusion. Two reviewers will independently screen all abstracts and full-text studies for inclusion. The included studies must focus on discussing critical illness. The results will be produced by using a thematic content analysis on the included studies. Background Due to the wide variety of definitions for critical illness, it is hard to define and estimate the burden of critically ill patients globally. It is estimated that 74 500 deaths occur every year only in the USA due to being critically ill, this number exceeds the yearly number of deaths from breast cancer, HIV/AIDS and asthma, this shows the underappreciated burden of critical illness. (1) When searching different databases there seems to be a wide variety of what the definition of critical illness is. Kumar et al. describe in their study the treatment and outcome in patients in Canada with 2009 influenza infection. They defined critically ill patients after 3 criteria depending on whether the patient was requiring mechanical ventilation or had deranged vital parameters (2). In another study by Vincent JL et al. They only look at patients with sepsis. (3) The absence of a reliable international data on critical illness is because of several challenges such as: Critical illness syndromes have a brief prodromal and high short-term mortality compared to other chronical diseases which could especially be high in countries with low to few intensive care unit (ICU) resources (1). When studying patients admitted to the ICU as critically ill, it seems like the outcome of patients admitted to the ICU differs even internationally due to differences in national income. In a study made by Vincent J et al. they examined 10 069 patients admitted to the ICU in Europe, Asia, Middle East, Oceania and Africa. The study suggests significant between-country variations in the risk of in-hospital death. They concluded that their findings highlight a significant association and stepwise increase between risk of death and the global national income and suggest that the ICU organization has a vital effect on the risk of death. (2) Why do we need to define critical illness? There is a need to academically and clinically discuss both improvements and implementations such as identifying patients with critical illness and ultimately decrease the mortality rate by receiving basic healthcare regardless of national income. There is a need for a national effort to prevent each of the complications leading to a critically ill patient as described by To K, Napolitano L (4). The first step is to find an internationally agreed definition for critical illness and would greatly benefit the increasing need for critical illness research and is not only limited to the ICU as patients who are critically ill is also present in other departments (2). Aim The aim of this study is to operationally define critical illness and attempt to answer the question: What are the main elements of existing definitions of critical illness and can these be homogenized to form a common definition? Design This study will be a scoping review complemented by a thematic content analysis including expert interview with health professionals working clinically to broaden the view. Rather than being dictated by a highly focused research question that forces the research on specific study designs, a scoping method is guided by the requirement to study all relevant literature regardless of study design. The scoping review methodology is particularly suited for questions not answerable by a systematic review because the scope is too broad. The review will be conducted using the Arksey and O’Malley framework and PRISMA-ScR hence first relevant studies will be identified, second studies will be selected for inclusion, third data will be charted and finally, the data will be summarized. (5, 6) References [1] Adhikari N, Fowler R, Bhagwanjee S, Rubenfeld G. Critical care and the global burden of critical illness in adults. The Lancet. 2010;376(9749):1339-1346. [2] Kumar A. Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada. JAMA. 2009;302(17):1872. [3] Vincent J, Marshall J, Ñamendys-Silva S, François B, Martin-Loeches I, Lipman J et al. Assessment of the worldwide burden of critical illness: the Intensive Care Over Nations (ICON) audit. The Lancet Respiratory Medicine. 2014;2(5):380-386. [4] To K, Napolitano L. Common Complications in the Critically Ill Patient. Surgical Clinics of North America. 2012;92(6):1519-1557. [5] Arksey H, O'Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1). [6] Tricco A, Lillie E, Zarin W, O'Brien K, Colquhoun H, Levac D et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018;. [7] Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & Health Sciences. 2013;15(3):398-405.

Background Traumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology. Methods This qualitative study investigated tele-experts’ (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis. Results Experts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback. Conclusion Experts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success – time pressure, intensity and the wide range of subspecialties to be considered. Electronic supplementary material The online version of this article (10.1186/s12911-018-0647-1) contains supplementary material, which is available to authorized users.

There is limited knowledge on the effect of seasonal flooding on health over time. We quantified the short- and long-term effects of floods on selected health indicators at public healthcare facilities in 11 districts in Cambodia, a flood-prone setting. Counts of inpatient discharge diagnoses and outpatient consultations for diarrhea, acute respiratory infections, skin infections, injuries, noncommunicable diseases and vector-borne diseases were retrieved from public healthcare facilities for each month between January 2008 and December 2013. Flood water was mapped by month, in square kilometers, from satellite data. Poisson regression models with three lag months were constructed for the health problems in each district, controlled for seasonality and long-term trends. During times of flooding and three months after, there were small to moderate increases in visits to healthcare facilities for skin infections, acute respiratory infections, and diarrhea, while no association was seen at one to two months. The associations were small to moderate, and a few of our results were significant. We observed increases in care seeking for diarrhea, skin infections, and acute respiratory infections following floods, but the associations are uncertain. Additional research on previous exposure to flooding, using community- and facility-based data, would help identify expected health risks after floods in flood-prone settings.

Background: Low retention of humanitarian workers poses constraints on humanitarian organisations’ capacity to respond effectively to disasters. Research has focused on reasons for humanitarian workers leaving the sector, but little is known about the factors that can elucidate long-term commitment. Objective: To understand what motivates and supports experienced humanitarian health workers to remain in the sector. Methods: Semi-structured interviews were conducted with 10 experienced nurses who had been on at least three field missions with Médecins Sans Frontières Sweden. Interviews explored factors influencing the decision to go on missions, how nurses were supported and how they looked back on those experiences. Transcripts were analysed through content analysis informed by van Gennep’s concept of ‘Rite of Passage’, combined with elements of the self-determination theory. Results: The findings indicate that their motivations and how nurses thought of themselves, as individuals and professionals, changed over time. For initiation and continued engagement in humanitarian work, participants were motivated by several personal and professional ambitions, as well as altruistic principles of helping others. When starting their first humanitarian missions, nurses felt vulnerable and had low self-esteem. However, through experiencing feelings of autonomy, competence and relatedness during missions, they underwent a process of change and gradually adjusted to new roles as humanitarian health workers. Reintegration in their home community, while maintaining the new roles and skills from the missions, proved very challenging. They individually found their own ways of overcoming the lack of social support they experienced after missions in order to sustain their continuation in the sector. Conclusions: The findings highlight the importance of social environments that facilitate and support the adjustment of individuals during and after field missions. Learning from positive examples, such as nurses with several years of experience, can strengthen strategies of retention, which can ultimately improve the delivery of humanitarian assistance.

Studies comparing provider and patient views and experiences of self-management within primary healthcare are particularly scarce in disadvantaged settings. In this qualitative study, patient and provider perceptions of self-management were investigated in five socio-economically disadvantaged communities in Stockholm. Twelve individual interviews and three group interviews were conducted. Semi-structured interview guides included questions on perceptions of diabetes diagnosis, diabetes care services available at primary health care centers, patient and provider interactions, and self-management support. Data was analysed using thematic analysis. Two overarching themes were identified. These were characterized by inherent dilemmas representing confusions and conflicts that patients and providers experienced in their daily life or practice respectively: adopting and maintaining new routines through practical and appropriate lifestyle choices (patients); and balancing expectations and pre-conceptions of self-management (providers). Patients found it difficult to tailor information and lifestyle advice to fit their daily life. Healthcare providers recognized that patients were in need of support to change behavior, but saw themselves as inadequately equipped to deal with the different cultural and social aspects of self-management. This study highlights patient and provider dilemmas that influence the interaction and collaboration between patients and providers with respect to communication and uptake of self-management advice.

Background Image-based teleconsultation between medical experts and healthcare staff at remote emergency centres can improve the diagnosis of conditions which are challenging to assess. One such condition is burns. Knowledge is scarce regarding how medical experts perceive the influence of such teleconsultation on their roles and relations to colleagues at point of care. Methods In this qualitative study, semi-structured interviews were conducted with 15 medical experts to explore their expectations of a newly developed App for burns diagnostics and care prior to its implementation. Purposive sampling included male and female physicians at different stages of their career, employed at different referral hospitals and all potential future tele-experts in remote teleconsultation using the App. Positioning theory was used to analyse the data. Results The experts are already facing changes in their diagnostic practices due to the informal use of open access applications like WhatsApp. Additional changes are expected when the new App is launched. Four positions of medical experts were identified in situations of diagnostic advice, two related to patient flow–clinical specialist and gatekeeper–and two to point of care staff–educator and mentor. The experts move flexibly between the positions during diagnostic practices with remote colleagues. A new position in relation to previous research on medical roles–the mentor–came to light in this setting. The App is expected to have an important educational impact, streamline the diagnostic process, improve both triage and referrals and be a more secure option for remote diagnosis compared to current practices. Verbal communication is however expected to remain important for certain situations, in particular those related to the mentor position. Conclusion The quality and security of referrals are expected to be improved through the App but the medical experts see less potential for conveying moral support via the App during remote consultations. Experts’ reflections on remote consultations highlight the embedded social and cultural dimensions of implementing new technology.

Background Point-of-care (POC) tests have become increasingly available and more widely used in recent years. They have been of particular importance to low-income settings, enabling them with clinical capacities that had previously been limited. POC testing programs hold a great potential for significant improvement in low-income health systems. However, as most POC tests are developed in high-income countries, disengagement between developers and end-users inhibit their full potential. This study explores perceptions of POC test end-users in a low-income setting, aiming to support the development of novel POC tests for low-income countries. Methods A qualitative study was conducted in Mbarara District, Southwestern Uganda, in October 2014. Fifty health care workers were included in seven focus groups, comprising midwives, laboratory technicians, clinical and medical officers, junior and senior nurses, and medical doctors. Discussions were audio-recorded and transcribed verbatim. Transcripts were coded through a data-driven approach for qualitative content analysis. Results Nineteen different POC tests were identified as currently being in use. While participants displayed being widely accustomed to and appreciative of the use of POC tests, they also assessed the use and characteristics of current tests as imperfect. An ideal POC test was characterized as being adapted to local conditions, thoughtfully implemented in the specific health system, and capable of improving the care of patients. Tests for specific medical conditions were requested. Opinions differed with regard to the ideal distribution of POC tests in the local health system. Conclusion POC tests are commonly used and greatly appreciated in this study setting. However, there are dissatisfactions with current POC tests and their use. To maximize benefit, stakeholders need to include end-user perspectives in the development and implementation of POC tests. Insights from this study will influence our ongoing efforts to develop POC tests that will be particularly usable in low-income settings.

The process of culture in implementation research: linking the clinic and the community in Stockholm

Household coping strategies during maternal and child health shocks in Lao People's Democratic Republic (PDR) are analysed in this paper. Vulnerability was the consequence of high and immediate medical costs, which forced households to borrow money or sell off assets, and also of poor access to health care as a result of these costs. This, in turn, resulted in income loss and health deterioration. Weaknesses in the health system contributed to vulnerability through low and unstable access to preventive services and limited monitoring of the conditions that threatened the health of women and children. Even when households received timely care, they could face long-term economic impacts as a consequence of their coping strategies. Copyright © 2014 John Wiley & Sons, Ltd.