Cross- cultural surveys: Experiences from the field Ans Luyben, PhD PGDE RM, R & D Midwifery.

Cross- cultural surveys: Experiences from the field

Ans Luyben, PhD PGDE RM, R & D Midwifery

Overview of presentation and workshop

Experiences of doing a cross- cultural doctoral

study:

1.What was done before I did it?

2.Why I did what I did?

3.What happened when I did it

4.And what I learnt….

Cross- national background

Born in the Netherlands 1961, trained and worked as a

midwife

Emigration to Switzerland in 1989, worked as a midwife and

teacher

PhD study Scotland 2001- 2008- looking for a topic for

study;

Doubt about content of (Dutch) antenatal care

Existing knowledge about antenatal care

Doctoral thesis Heringa (1998), based on study of Hall in Aberdeen (1985)

Experiences of care providers in practice

Studies on effectiveness Effectiveness and satisfaction in antenatal care Effective care in pregnancy and childbirth Cochrane Library, for example Villar 2001

Other studies, particularly those carried out in Europe

Summary existing knowledge

1920s: Introduction of antenatal care in Europe

Effectiveness determined based on traditional

statistical outcome (mortality, morbidity)

1950s: Introduction of confidential enquiries

1989: Effective care in pregnancy and childbirth

2000s: Assessments of content still inconclusive

Women‘s complaints hardly changed

Primary research question

What is effective content of antenatal care in Europe?

Existing cross- national studies

Comparative surveys and studies in Europe WHO 1979- 1984 HSRC of EU: Heringa & Huisjes 1988 Barriers and Incentives to Prenatal Care 1994 EuroNatal Study 1996 PERISTAT 2003

Several others, like: ESS, OECD, EMA Haertsch, Langer Villar et al.

WHO Study 1979- 1984

Questions: What is known about women‘s and children‘s health

around childbirth? What health care services are available? How big is the gap between what is known and what is

being done? (or not being done)

Included: 23 countries

Methods: Systematic literature review Two surveys (organisation/ content, psychosocial) Observations of experiences in care

WHO Study 1979- 1984

Some results: Wide variety of programmes with similar MMR or PMR Antenatal care should be improved by a better combination

of medical and social care Effectiveness of risk selection should be assessed Role of primary provider should be reconsidered Interventions, including risk selection should be better

evaluated, eg. in RCTs Evaluation should include the role of the client/ provider

relationship Women should be empowered by determining their health

needs, planning and evaluating their care

Heringa and Huisjes 1988

Health Services Research Committee EU 1986:- Aiming for harmonisation of systems- Evaluation of efficacy, effectivenes, costs and

psychological and social impact

Heringa & Huisjes 1988:Evaluation of existing screening procedures: Literature review Survey in 67 tertiary hospitals, questionnaire

with closed questions (30 procedures)

Heringa and Huisjes 1988

Results: Wide variation of 11 to 24 routinely performed

screening tests between as well as within countries

Only 5 tests in common: blood pressure, glycosuria, weight, blood group/ Rhesus and fundal height

Effectiveness for many procedures was lacking

„Benefits of routine screening are probably overestimated and disadvantages undervalued“

„Barriers and Incentives“ 1994

Premise: Uptake of antenatal care improves pregnancy outcomes

Aim: Studying the utilisation of antenatal care, in particular under- or overutilisation

Included: 17 European countries

Multi- study design, included:- attendance of antenatal care- incentives - organisation related to utilisation and PMR

„Barriers and Incentives“ 1994

Results: No relationship between incentives and

attendance of antenatal care

Variety in attendance, but women‘s reasons for non- or late attendance were not studied

Large variety in services, equally effective in regard to PMR

More information needed about relationships between the players and characteristics of the systems

EuroNatal Study 1996

Aim: Determining the validity of PMR as an outcome indicator for the quality of antenatal and perinatal care

Assumption: PMR can be reduced by 25% by improved standards of care

Included: 11 countries

Design:- investigation in different registration practices- investigation of risk factors influencing PMR by auditing individual cases

EuroNatal Study 1996

Results: 1619 anonymous cases of perinatal death

between 1995 and 1998 Linked to prevalence and clinical guidelines

715 cases of suboptimal care Major factors: failure to detect and treat intra-

uterine growth retardation and maternal smoking

Recommendation:- improvement of quality of care- identification of determinants of quality of care

PERISTAT 2003

Aim: Develop indicators for monitoring and describing perinatal health in Europe

Included: 15 countries

Process:- review of existing international and national perinatal health indicators by experts- Delphi consensus process with a scientific committee in order to determine indicators- feasibility study in involved countries as to assess their use in practice

PERISTAT 2003

Results: Four categories of indicators: fetal/ neonatal

health, maternal health, sociodemographic associated with health outcomes and health services

Few lacking indicators in regard to women, eg. „support to women“ and „maternal satisfaction“

Feasibility: some indicators were not available, some had different definitions and demographic differences influenced their values

Villar et al. 2001

Aim: Prove evidence of effectiveness of an antenatal programme with a reduced number of visits and reduced content in four developing countries

Setting: Argentina, Cuba, Saudi Arabia and Thailand

Design: Systematic literature review Randomised controlled trial with cluster

randomisation, including compliance and process outcomes (service use)

Cost- effectiveness Women‘s and provider‘s perceptions

Villar et al. 2001

Results:Routine antenatal care can be provided with a reduced

number of visits and content without affecting its medical effectiveness

Primary and secondary clinical outcomes similar, although rates of pre- eclampsia higher in new model

Health care costs similar, or even less in new model Care providers were satisfied as long as modifications

„did not limit their clinical control“ Women were „satisfied“ with new model, but… Provision of support should be provided by other

means than „formal encounters with medical providers“

Concept analysis of effectiveness

Perspectives Women Biological/ epidemiological

Other(s) disciplines

Antecedents/Aims

Becoming a mother; own and family health

Reduction of PMR, MMR and morbidity

Variety

AttributesQuality, satisfaction, experience

Clinical effectiveness

Terminology varying e.g. evaluation

Consequences/ Indicators

(Dis-) Satisfaction,experience

Biomedical/ epidemiological outcome

Variety- little available and comparable

Evaluation methods

Surveys, qualitative interpretive

Quantitative, deductiveRCTs

Depending on agent and perspective

Research question

What is effective content of (Westeuropean) antenatal care from women‘s points of view in the

Netherlands, Scotland and Switzerland?

Methodology and methods

Several considerations:

Top- down or bottom- up approach ? Deductive or inductive ? Descriptive or analytic ? Access and availability ?

Methods ?

Methodology and methods

Constructionist epistemology

Interpretive ontology

Grounded theory

Symbolic interaction

Interviews, and possibly other material

Settings and access

Cross- national or - cultural

Three languages

Three health care systems

What is culture?

„A set of explicit and implicit guidelines which people learn from a particular society and which informs them on how to view the world, how to experience it emotionally, and how to behave in it in reaction to other people, to the supernatural and to the natural environment.“ (Helman 2007, p. 2)

GT considerations in regard to culture

Symbolic interaction:Culture is the self- defined social world of the participants based on joint meanings of symbols

Meanings are a consequence of the research process; they can not be defined in advance

The field is addressed as one unit, and every variable has to earn ist place in the theory based on the relevancy for women

Need for cultural neutrality and sensitivity (familiarity)

What is language?

Symbolic interaction: Joint meanings of symbols created through interaction with the social world (Mead 1967)

Coding in Grounded Theory:Translating language into a secret set of symbols (Dey 1999)

Minimal translation (Barnes 1996, Strauss and Corbin 1998)

This meant that meanings had to be created (coding) with women in one language, before creating meaning (coding) between all languages

Design: Grounded Theory with Units

Continuous comparison

Theoretical sampling

Maternity care in the 3 countries

Care Switzerland Holland Scotland

Place Private practice or hospital

Midwifery practice or hospital

Health care center or hospital

Persons Gynaecologist (Midwife)

Midwife(Obs/ Gyn)

Shared care

Content KVG, varies Interprofessio-nal guideline

Framework for Scotland NHS

Philosophy Decentral organisation and choice of care provider

Maintenance of divisions of echelons

Health care for all in need

Gaining access and ethical approval

- Knowing the system- Having some relevant informants- Speaking the language, knowing the culture- „Being there“ or „having been there“

Recruiting and sampling

Information and consent forms in 3 languages First sample convenience sample (variation)- clear

communication about sampling if more persons involved

Other samples: theoretical samples

12 women 10 women 10 women

14 interviews 12 interviews 12 interviews

Data collection and field experiences

Organisation of units of interviews, planning in advance

Semi- structured one- to- one interviews by one researcher in women‘s own languages, tape recorded, minimum interview guideline

Excellent way of „meeting“ the context Differences in set up of meetings

Field notes, role of field notes

Collection of information in practices and hospitals

Data analysis

Transcription in own language Coding in own language Categorising; primarily in own language, then

into the overall unit, using the distinction between an „etic“ and „emic“ dimension (Brislin et al 1973); what fits and what is different ?

Four memobooks; one in Dutch, Swiss- German and English and one for the overall unit

Theoretical sampling; looking for largest variation No software used for qualitative analysis

Coding and categorising „live“

Netherlands Scotland

Results after analysis first sample

Category Scotland Switzerland Netherlands

Responsibility X X X

Autonomy X, „control“ ~, not content but organisation

X, also „letting go“

Confidence X X X

- Information X (++) ~ X

- Environment X X X (+)

- Baby ~ ~, partly X

- Care provider ~ X X

Results I: Model of Effective Maternity Care

Results III: Model of Content of Care

Conclusions and implications

Effective maternity care needs:

• Mentorship model of maternity care• Choice of an experienced care provider• Sharing woman- care provider partnership• Women- and process- orientated content of care• Continuity of care and carer; from beginning of pregnancy

to about one year after giving birth• Involvement of women‘s social environment

Reality in the three countries

Category Scotland Switzerland Holland

Being experienced + + +

Providing a familiar environment

~ ~ +, if bond

Guidance (care) ~, access/ attitude ~, attitude/ bond +, attitude/ bond

Raising awareness + + +

Sharing awareness ~ ~/+ +

Closing awareness +, self ~/+ +

Being there +/ ~ ~/+ +

Support ~ ~/+ +

Releasing ~ ~ +/~

Results III: Creating a bond with a care provider

„Someone who is always there for me..“

Finding access Approaching Being familiar

Reality in the three countries

Category Scotland Switzerland Holland

Someone who is always there for me

Shared care Gynaecologist MidwifeGynaecologist

Finding access HospitalHealth center

Private practice Private practiceHospital

Approaching MidwifeGynaecologistKnown ???

GynaecologistMidwife

MidwifeGynaecologist

Being familiar ? ? Midwife

Reality in the three countries

Effective care: what happens if not continuous?

Category Netherlands Switzerland Scotland

Expert/Reference

Information/ Raising awareness

Sharing

Support

Guidance

Releasing

Some points of experience

One size does not fit all…. „English speaking empirialism“ in literature Underpinning philosophies of systems are very

important Language= not language, even in English Words are not always what they seem. Dialectical

construction of meaning is an extremely valuable tool Competence of multi- cultural, multi- language

researchers (vs. translators eg. Squires 2009) is underestimated

The biggest issue in qualitative research done this way is not bias of the researcher, but her loss of reference, which might be a reason why most prefer deductive approaches

Some open questions

1. Is what we do important?

2. Do we do what we think we do?

3. Are we measuring what we want to measure?

(according to Heringa 1998)

Thank you !