| 1. |
- Vallerossa, Francesco, 1992-
(författare)
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Learning aspect in Italian as a third language : Transfer patterns among multilingual learners in the Swedish context
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis explores the impact of previously acquired or learned background languages (BL) on the learning of Italian as a third language (L3) among undergraduate students in the Swedish context. Focusing on the learning of past tense-aspect (TA) inflectional categories in Italian, the thesis investigates the influence of Swedish, English and Romance languages, French or Spanish, in light of four factors. The typology factor entails the linguistic similarity between the L3 and the BLs. The language status factor examines the different roles played by first (L1) and second (L2) languages. The proficiency factor refers to proficiency in both the L2s and the L3. The prototype factor deals with different combinations of grammatical and lexical aspect, defined as prototypical and non-prototypical. Eight Italian native speakers and 36 undergraduate students learning Italian in Sweden were included in the studies making up the thesis. The learner group had knowledge of Swedish and English. A majority had additional knowledge of a Romance language, which allowed for a distinction to be made between a non-Romance and a Romance group. The participants completed a background questionnaire and a test battery of seven tests consisting of three C-tests (French, Spanish, and Italian), three interpretation tests of aspectual contrasts (English, French, and Italian), and an oral retelling story test in Italian. The data were analyzed quantitatively, by means of descriptive and inferential statistics, and qualitatively, through content analysis. Study I probed the impact of typology, L3 proficiency and prototypes on oral production data. At low-proficiency levels, prior L2 knowledge of a Romance language favored the emergence of imperfective morphology in L3 Italian while learners at high-proficiency levels were sensitive to prototypes. Based on interpretation data, Study II went further into the role of typology, L2 proficiency and prototypes, revealing a beneficial effect of English and Romance languages, except with non-prototypical associations. Study III looked into typology and L2/L3 proficiency. Four categories, differently distributed depending on L2/L3 proficiency, unfolded from written introspection data submitted to qualitative content analysis: explicit rules, intuition, other languages and uncertainty/unknown. Study IV, closely examining three participants with different acquisition orders of Swedish, English and French, showed an interaction of the language status with L3 proficiency, typology and prototypes. Overall, the results indicate that all BLs impact the learning of prototypical associations, while the L1 alone influences learning of non-prototypical associations. Further, the typology factor and the L2 proficiency factor are crucial for transfer of forms and transfer of meanings, respectively. The influence of the BLs is prevalent at early acquisition stages while advanced stages are uniformly shaped by prototypes. Also, learners gradually add different layers of information to their explicit knowledge of tenses. The results align with L3 accounts arguing for property-by-property hybrid transfer. The thesis further connects L3 transfer research focusing on linguistic and conceptual transfer to research on learning TA morphology. In light of the above contributions, the thesis recommends explicit crosslinguistic instruction aiming to foster positive transfer through tailor-made use of the learners’ BLs.
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| 2. |
- Alvebratt, Caroline
(författare)
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Advanced Methods for Evaluation of the Performance of Complex Drug Delivery System
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Low oral bioavailability of drugs originating from poor aqueous solubility is a common issue in drug development. Various enabling formulations have been presented to circumvent this limitation, many making use of supersaturation. In these, the drug is delivered to the gastro-intestinal lumen in a high energy state e.g. in amorphous form or a liquid lipid vehicle. Concentrations surpassing the equilibrium solubility of the crystalline drug are achieved, which facilitate increased absorption for dissolution-rate limited compounds. Meanwhile the use of the enabling formulation can be beneficial to increase the bioavailability of poorly water-soluble drugs, in vitro evaluation of these systems remain challenging. Limited methods have also evaluated several different types of enabling formulation in the same experimental setup. The overall aim of this thesis was therefore to develop assays to study the performance of various complex drug delivery systems. In the first part, a small scale dissolution apparatus, the µDiss Profiler, was used to study drug release from drug-loaded mesoporous magnesium carbonate (MMC). A protective filter was developed to minimize particle interference on the UV-measurements, enabling studies of supersaturation from the amorphous carrier. In the second paper, lipids were adsorbed onto the MMC. A modified in vitro lipolysis setup was established and the samples were analyzed with nuclear magnetic resonance spectroscopy. A stability study of the lipid-loaded MMC was also performed. The methods developed in the first two projects provided an insight to events occurring in the intestinal lumen. The intestinal absorption has however been shown to be a complex interplay between dissolution-digestion and permeation. In the final two projects, two devices comprising of a donor (luminal) chamber and a receiver (serosal) chamber were studied (the µFLUX and the enabling absorption, ENA, device). The two chambers were separated by a semipermeable membrane (cell-based and/or phospholipid-based). A wide range of enabling formulations were evaluated in the two assays. As the exposure in the donor correlated poorly with the exposure in the receiver compartment, this emphasizes the importance of in vitro methods taking both the dissolution-digestion and permeation into account. The ENA results also predicted the in vivo performance in rats well. To conclude, several models have been established in the thesis to study the in vitro performance of enabling formulations, which will be valuable for screening of appropriate drug delivery systems.
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| 3. |
- Arnqvist, Johan, 1985-
(författare)
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Mean Wind and Turbulence Conditions in the Boundary Layer above Forests
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- As wind turbines have grown, new installation areas become possible. Placing wind turbines in forested landscapes introduce uncertainties to the wind resource estimation. Even though close-to-canopy processes have been studied intensively during the last thirty years, the focus has mostly been on exchange processes and the height span of the studies has been below the rotor of a modern wind turbine.This thesis contains analysis of new measurements from a 138 m high tower in a forested landscape. The previous knowledge of near-canopy processes is extended to the region above the roughness sublayer. It is shown that above the roughness sublayer, the surface layer behaves as over low vegetation, and Monin-Obukhov similarity is shown to hold for several variables. However, in stable stratification, effects that could be linked to the boundary layer depth are shown to be present in the measurements. These include wind turning with height, the behaviour of the turbulence length scale and the curvature of the wind profile.Two new analytical models are presented in the thesis. One is a flux-profile expression in the roughness sublayer, which allows for analytical integration of the wind gradient. The model suggests that the roughness-sublayer effect depends on stratification and that the aerodynamic roughness length changes with stability. A decrease of roughness length in stable stratification is confirmed with a new method to determine the roughness length using measurements from the 138 m tower.The other model determines the spectral tensor in stable stratification using analytical solution to the rapid distortion equations for stratified shear flow, with homogeneous stratification and shear. By using a formulation for the integration time of the distortions of an isotropic spectrum, a model is derived which provides the cross spectra of velocity and temperature at any two given points in space.Finally the existence of waves in the wind over forests is investigated and it is concluded that the Kelvin-Helmholtz instability can create waves which are coherent in time and exist over the entire height span of wind turbine rotors. Linear wave theory is shown to be able to explain certain features of the waves.
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| 4. |
- Bergström, Anna
(författare)
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Evidence and context : knowledge translation for newborn health in low-income settings
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Neonatal mortality (death within the first 28 days of life), presently accounts for 41% of the global burden of under-5 deaths. Estimates indicate that about two-thirds of the 3.1 million neonatal deaths could be averted with an increased implementation of existing evidence-based practices. Neonatal hypothermia, defined as body temperature <36.5°C, contributes to the burden of neonatal mortality and can easily be avoided and managed by practicing delayed bathing and by applying skin-to-skin care of the newborn. However, neonatal care routines in many low-income countries do not yet adhere to these evidence-based practices. In addition, misconceptions - such as beliefs that skin-to-skin care enhances vertical HIV transmission and that early bathing is required continue to exist. These misconceptions further delay knowledge translation. The Promoting Action on Research Implementation in Health Services (PARIHS) framework is a conceptual framework that posits three interacting cornerstones: (1) Evidence, (2) Facilitation and (3) Context, that, taken together, influence implementation of new knowledge. Improved understanding of how contextual factors in healthcare organizations influence knowledge translation has led to the development of context assessment tools for high-income settings. There are no tools available for this purpose in low- and middle-income settings. Aims: To increase the body of knowledge on thermal response in newborns and mothers to inform evidence-based clinical practices, explore perceptions around these practices amongst newly delivered mothers and, furthermore, to explore the perceived influence and relevance of factors in the organizational context on the implementation of evidence-based practices in low- and middle-income settings. Methods: The studies employed both quantitative (I, III, V) and qualitative (II, IV-V) methods. Studies I- III were undertaken in Uganda and focused on generating evidence around thermal control of the newborn. Neonatal rectal and tympanic temperatures were measured at 5, 60, 70 and 90 minutes postpartum amongst 249 mother-newborns pairs. All newborns were subjected to skin-to-skin care. The pairs were randomized to either bathing in lukewarm water at 60 minutes (n=126) or into continuous skin-to-skin care (n=123) throughout the study period (I). In order to explore perceptions of skin-to-skin care, 30 purposively sampled women having participated in Study I were invited to participate in focus group discussions (II). In order to deepen the understanding of how skin-to-skin care affects the maternal temperature, maternal breast and axillary temperatures were assessed at fixed intervals postpartum whilst practising skin-to-skin care of the newborns (III). Studies IV-V focused on generating a better understanding of factors in the organizational context that influence the implementation of new knowledge. Focus group discussions and individual interviews were undertaken amongst health workers and managers in Uganda (IV) and content validity of available tools and developed items were assessed quantitatively and qualitatively amongst identified experts in Bangladesh, Vietnam, Uganda and Nicaragua (V). Descriptive statistics, chi-square test and logistic (I) and linear (III) regression analysis methods were applied to model the relationship between the dependent variable, temperature, and the explanatory variables. Content analysis was applied to the qualitative studies (II, IV-V). Rated content validity of context concepts were assessed by calculating content-validity index (CVI) (V). Results: The effect of bathing resulted in a significant increase in point-prevalence of hypothermia at 70 minutes postpartum amongst newborns having been exposed to bathing compared to those who were not (p=<0.001). This difference amongst the two groups was sustained throughout the study period. Cultural beliefs and lack of knowledge were found to influence women’s perceptions of skin-to-skin care (II). In study III, a rapid maternal thermal skin response was detected following the application of skin-to-skin care (p=<0.0001). In addition to the sub-elements of the context cornerstone in the PARIHS framework (leadership, culture and evaluation) we found that resources, commitment, informal systems and payment as well as community involvement were important aspects of context influencing knowledge translation low- and middle-income settings (IV-V). In study V, we found that all the assessed concepts were perceived as relevant and a total of 28/94 tested items were also rated as relevant (Item-CVI >0.78). Conclusions: Continuous skin-to-skin care reduces the prevalence of hypothermia but its application does not prevent the negative thermal effect of early bathing. There are misconceptions about thermal care of the newborn and there is a need to clarify how patient preferences are to be perceived as evidence in the PARIHS framework. In the studied healthcare settings, resources, community engagement and informal payment and commitment are relevant aspects of context, in addition to leadership, culture and evaluation, as suggested in the PARIHS framework. There is a need to adapt the PARIHS framework and tools to assess context and commitment to fit low- and middle-income settings.
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| 5. |
- Bergström, Anna
(författare)
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Renal cell cancer : the role of physical activity and body size
- 2001
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to explore how physical activity, obesity, weight change, and birth weight influence the risk of renal cell cancer. The relation between occupational physical activity and risk of renal cell cancer was studied in a cohort of Swedish men and women identified in the nationwide censuses in 1960 and 1970, and followed for the occurrence of cancer by linkages to the Swedish Cancer Registry 1971-1989 (Paper I). We identified 2,704 male and 587 female cases with the same level of occupational physical activity in 1960 and 1970 (n=674,025 men and 253,336 women). In multivariate models, men with long-term sedentary jobs had a 25% increased risk compared to men with physically demanding occupations. In contrast, we found no clear evidence of an association between occupational physical activity and renal cell cancer risk among women. The association between occupational and leisure time physical activity and renal cell cancer risk was further studied in a prospective cohort of 17,241 Swedish twins (Paper II). Exposure information was obtained through a mailed questionnaire. During follow-up from 1967 through 1997 we identified 102 renal cell cancer cases. We found no evidence of a significant association between either occupational or leisure time physical activity and risk of renal cell cancer in this cohort. To evaluate the existing evidence that obesity increases the risk of renal cell cancer among both men and women, we conducted a quantitative summary analysis of published studies (Paper III). Fourteen studies on each sex assessed obesity as body mass index (BMI, kg/m 2), or equivalent, and were included in our analysis. In contrast to previous qualitative reviews, our quantitative summary showed that increased BMI is equally strongly associated with renal cell cancer risk among both men and women. The risk increased by 7% per one unit of increase in BMI (1 kg/m2 , corresponding to about 3 kg body weight increase for a subject of average height). The relation between body size and renal cell cancer was evaluated in more detail in a population-based case-control study with 877 patients with newly diagnosed renal cell cancer and 1,508 control subjects, frequency-matched by age (Paper IV). Exposure information was obtained through a mailed questionnaire. General and abdominal obesity (measured as BMI and waist-to-hip ratio, respectively) were independently associated with increased risk of renal cell cancer among both men and women. Furthermore, tall height was associated with an increased risk among both sexes. Weight gain and repeated weight changes in adult life were associated with an increased risk, especially among those with a high BMI already at age 20. The relation between birth weight, a marker of fetal nutrition and growth, and renal cell cancer was evaluated in the case-control study described above (Paper V). A total of 648 cases and 900 control subjects reported their birth weight and were included in the analyses. An increased risk of renal cell cancer was suggested among men with a high (>3500 g ) birth weight, compared to men with a birth weight between 3000 and 3499 g. We found no clear association among men with a low (<3000 g) birth weight, or among women. Our study shows that conditions in utero, reflected by birth weight, might affect the risk of renal cell cancer in adulthood.
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| 6. |
- Bergström, Anna, 1971-
(författare)
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Winter maintenance and cycleways
- 2002
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Increasing cycling as a means of personal travel couldgenerate environmental benefits if associated with acorresponding decrease in car-based transport. In seeking topromote cycling in wintertime, it is desirable to understandhow important the road surface condition is compared to otherfactors in people's decision to cycle or not. In this thesis,the possibility of increasing the number of cyclists byimproving the winter maintenance servicelevel on cycleways isexamined. The attitudes towards cycling during winter ingeneral, and in relation to winter maintenance of cycleways inparticular, is studied through questionnaire surveys. Bicyclemeasurements are related to weather data from Road WeatherInformation System, in order to know the influence on cycleflow during winter from different weather factors. Fieldstudies are performed testing unconventional winter maintenancemethods, in order to see if a higher service level could beachieved on cycleways and if that would lead to an increase inwinter cycling frequency. The field studies are evaluatedthrough road condition observations, measurements of friction,bicycle counts, a questionnaire survey and interviews. A visualmethod to assess winter road conditions on cycleways isdeveloped, in order to compare the service levels achievedusing different winter maintenance methods.There is a clear difference in mode choice between seasons.With improved winter maintenance service level it could bepossible to increase the number of bicycle trips to work duringwinter with, at the most, 18 %, and decrease the number of cartrips with 6 %. However, it could not be concluded with bicyclemeasurements, that an enhanced service level in fact, generateda higher winter cycling frequency.To increase cycling during winter, snow clearance is themost important maintenance measure. Skid control is not assignificant for the choice of mode but is important to attendto for safety reasons. Winter road condition propertiesimportant both with regard to safety and accessibility ofcyclists, are icy tracks formed when wet snow freezes, snowdepths greater than about 3 cm of loose snow or slush,unevenness in a snow covered surface, loose grit on a baresurface.Weather factors with negative influence on winter cyclingfrequency, are temperatures below +5 ° C,precipitationand strong winds. Only the occurrence of precipitation, not theamount of rain or snow, is significant for the cycle flow. Lowtemperatures are more important in reducing the cycle flow thanprecipitation. Temperatures around 0 ° C seem to be extracritical for cyclists, probably due to the larger influence ofprecipitation and slippery road conditions at thesetemperatures.An unconventional method using a power broom for snowclearance and brine or pre-wetted salt for de-icing, provides ahigher service level than winter maintenance methodstraditionally used, but it is about 2 to 3 times moreexpensive. The method has great potential in regions, such assouthern Sweden, with low snow accumulations but with major iceformation problems. To assess the maintenance service level,the visual assessment method developed and tested in thisproject is adequate for the purpose, however, furtherimprovements are desirable. As a complement to the visualassessment, a Portable Friction Tester can be used to measurethe surface friction on cycleways during wintertime.Keywords:Cycleways, winter maintenance, maintenanceservice level, mode choice, winter cycling frequency, wintermaintenance equipment, winter road condition assessment,bicycle measurements, friction measurement.
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| 7. |
- Bergström, Sofia
(författare)
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Multiplexed antibody-based protein profiling in the pursuit of CSF biomarkers for neurodegenerative diseases
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- There is a desire for a transition from generic treatments designed for the average patient, towards more individual-based precision medicine. An increased knowledge about disease pathophysiology on a molecular level would be beneficial for this transition. The study of proteins can contribute with valuable insights into etiology and pathogenesis of different diseases and thereby aid the clinical assessment of patients and guide future treatments.Neurodegenerative disorders, such as Alzheimer’s disease, Parkinson’s disease, and frontotemporal dementia, are characterized by a progressive loss of function, and eventually death of neurons. Neurons allow the brain to communicate with the rest of the body, and a deteriorated function of neurons can result in problems with mobility or mental functions. Neurodegenerative diseases progress slowly over many years, with a long silent asymptomatic phase before symptom onset. It is hard to rebuild what is already lost, but disease-modifying treatments might be able to slow down or halt the deterioration of the brain. Therefore, there is a major research focus on investigating the early stages of disease pathogenesis in order to elucidate this critical phase in disease progression.The four papers included in this thesis focus on identifying altered protein profiles in cerebrospinal fluid from patients with neurodegenerative diseases. For this purpose, multiplexed antibody-based suspension bead arrays have been used. This method allows for hundreds of proteins to be analyzed in hundreds of samples in the same assay. Paper I focuses on Alzheimer’s disease and investigates the profiles of 200 proteins when comparing patients with controls. Six proteins were identified at altered levels and were further investigated in relation to the progression from mild cognitive impairment to Alzheimer’s disease. Paper II explores 100 protein profiles in relation to the core Alzheimer’s disease biomarkers in asymptomatic 70-year-olds to elucidate patterns preceding potential disease onset. Paper III investigates the transition to cognitive impairment in patients with Parkinson’s disease and explores potential associations between protein profiles and cognitive assessment tests. Finally, Paper IV explores panels of proteins in the context of frontotemporal dementia. Panels of proteins, instead of single biomarkers, have an increased potential to capture the range of biological processes within these types of complex and multifactorial diseases.Neurodegenerative diseases are often heterogeneous which puts high demands on the study design including an appropriate selection of study population. However, significant similarities are also present which makes it advantageous to have a broad perspective and work with several neurodegenerative disorders. This thesis presents the results from multiplexed antibody-based protein profiling as a contribution to a better understanding of neurodegenerative diseases.
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| 8. |
- Birgner, Carolina, 1978-
(författare)
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Anabolic androgenic steroids and central monoaminergic systems : Supratherapeutic doses of nandrolone decanoate affect dopamine and serotonin
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Supratherapeutic doses of anabolic androgenic steroids (AASs) are administered, not only as performance-enhancing drugs in the world of sports, but also in order to modify behaviour. AAS abusers are at risk of developing serious physical and psychological side effects such as dependence and aggressive behaviour. The aim of this thesis was to investigate the impact of supratherapeutic doses of nandrolone decanoate after subchronic administration on dopamine and serotonin pathways involved in drug dependence and aggression, in the male rat brain.Adult male Sprague-Dawley rats received intramuscular injections of nandrolone decanoate (3 or 15 mg/kg) or vehicle once daily for 14 days. Nandrolone decanoate pre-exposure abolished the effect of amphetamine on the 3,4-dihydroxyphenylacetic acid (DOPAC) tissue level in the hypothalamus and on the DOPAC/dopamine ratio in the hypothalamus and the hippocampus. A significant decrease of the basal extracellular DOPAC and homovanillic acid (HVA) levels could be detected in the nucleus accumbens, which remained low during the first hour following the amphetamine challenge. Nandrolone decanoate significantly reduced the activity of both monoamine oxidase A and B (MAO-A and -B) in the caudate putamen and amygdala. The gene transcript levels of MAO-B, and the dopamine D1 and D4 receptors were altered in limbic regions. No changes in transcriptional levels could be detected among the serotonin receptor genes examined. However, the density of the serotonin transporter protein was elevated in a range of aggression-related brain regions.Taken together, subchronic administration of nandrolone decanoate causes dopaminergic and serotonergic dysregulations in distinct brain regions. These areas of the brain are involved in the development of drug dependence and expression of impulsive and aggressive behaviours. These results may contribute to explain some of the behavioural changes often reported in AAS abusers, such as polydrug use and impaired impulse control.
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| 9. |
- Brolin, Emma
(författare)
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Pathophysiological effects of alpha-synuclein on SNARE complex proteins in models of alpha-synucleinopathies
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Accumulation and spread of alpha-synuclein (α-syn) aggregates are central to the disease pathogenesis of Parkinson’s disease and dementia with Lewy bodies, collectively known as α-synucleinopathies. Native α-syn is a monomeric presynaptic protein that can act as a molecular chaperone for the soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) complex assembly. The aim of this thesis was to investigate the pathophysiological effect of different α-syn species on SNARE protein distribution and to study the involvement of extracellular vesicles (EVs) in the propagation of α-syn pathology.In paper I, the co-localization between α-syn and the SNARE proteins VAMP-2, SNAP-25 and syntaxin-1, was analyzed in primary cortical neurons from transgenic (tg) human A30P α-syn and wild type (wt) mice using proximity ligation assay (PLA). The results demonstrated that SNARE proteins co-localized with total α-syn mainly in neuronal processes, and with A30P α-syn predominantly in the cell soma. In paper II, we investigated how altered molecular properties of α-syn could affect its cellular processing. Different α-syn constructs were expressed in SH-SY5Y cells and the culture medium was analyzed for free-floating α-syn, as well as for α-syn within the EV fraction. Modifications in the N-terminal increased the EV secretion and enhanced the cell-to-cell transfer of α-syn. In paper III, the synaptic α-syn species of the A30P tg mouse brain were biochemically characterized and their effect on SNARE protein distribution was analyzed with western blot and PLA. We found that synaptosomal α-syn aggregates were mainly composed of non-phosphorylated human A30P α-syn. A decrease of intact SNARE complexes was observed in the tg A30P synaptosomes and in the prefrontal cortex, even though the total levels of SNARE proteins were unchanged in A30P compared to wt mice.In paper IV, we studied the effect of α-syn monomers and α-syn preformed fibrils (PFFs) on SNARE protein distribution in wt primary neurons, using PLA. Both short- and long-term exposure to α-syn monomers or PFFs altered the co-localization of SNARE proteins. Promoting the long-term uptake of α-syn by using a protein delivery reagent, further increased SNARE protein redistribution. In contrast, a PFF-induced SNARE protein redistribution was not observed when lysosomal degradation was inhibited. Interestingly, addition of EVs from monomer- and PFF-treated astrocytes also affected SNARE protein distribution in recipient neurons. Taken together, the results from this thesis indicate that synaptic α-syn aggregates and EV-associated α-syn could be promising therapeutic targets in the α-synucleinopathies.
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| 10. |
- Brunell, Olivia
(författare)
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Improving neonatal health care in Nepal
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Every year, millions of newborns die globally due to poor quality of care around the time of birth. The overall aim of this thesis was to inform and test design of quality improvement (QI) interventions in Nepal. Contextual factors of importance for implementation of evidence-based newborn care practices were investigated, and the effect of a package of QI interventions on provision and experience of care was evaluated. In Paper I, we used focus group discussions and key informant interviews with delivery care staff to identify barriers and enablers for delayed umbilical cord clamping (DCC). Results indicate that delivery care staff needed knowledge of the benefits of DCC to gain motivation for change. Training, supervision and evaluation were requested to be able to change old routines, and they wanted authorized guidelines to bring uniformity in clinical practice. In Paper II, individual interviews with staff working with newborn infants were used to explore factors affecting parent-infant closeness in hospitals. Informants thought that offering a comfortable environment, privacy and counselling would enhance parent-infant closeness, but hospital resources were insufficient to achieve this. They described routines in the hospitals, and traditions and cultural beliefs in the society, which separated parents and newborns. In Paper III, a stepped-wedge randomized control design was applied to evaluate the effect of a QI package including training, facilitation and feedback, on patient satisfaction. The likelihood of women being overall satisfied with care during childbirth increased (aOR 1.66 [CI: 1.59-1.73, ICC: 0.275]) but the overall proportion of satisfaction was low, increasing from 58% to 62%. In Paper IV, clinical observations of early essential newborn care (EENC) practices were done before and after the introduction of the QI package. Overall, the rate of initiation of breastfeeding within one hour increased from 5% to 12%, and DCC increased from 22% to 33%. In conclusion, when designing interventions to improve quality of care, in Nepal or similar settings, it is important to use authorized guidelines and include education, training, supervision and evaluation. Hospital resources, routines and cultural beliefs need to be considered. The results indicate that a multi-pronged QI package can improve quality of newborn care in Nepal.
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