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1.	Bergström, Anna, 1983-, et al. (author) The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature 2020 In: Implementation science : IS. - : Springer Science and Business Media LLC. - 1748-5908. ; 15:1 Research review (peer-reviewed)abstract BACKGROUND: The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework. METHODS: This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail. RESULTS: The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated. CONCLUSIONS: In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.
2.	Nilsson, Erik, 1983-, et al. (author) Comparison of CO2 fluxes measured in dried and un-dried air 2015 Conference paper (other academic/artistic)
3.	Nilsson, Erik, 1983-, et al. (author) Evaluating humidity and sea salt disturbances on CO2 flux measurements 2018 In: Journal of Atmospheric and Oceanic Technology. - 0739-0572 .- 1520-0426. ; 35, s. 859-875 Journal article (peer-reviewed)abstract Global oceans are an important sink of atmospheric carbon dioxide (CO2). Therefore, understanding the air-sea flux of CO2 is a vital part in describing the global carbon balance. Eddy covariance (EC) measurements are often used to study CO2 fluxes from both land and ocean. CO2 are usually measured with infrared absorption sensors, which at the same time measure water vapor. Studies have shown that presence of water vapor fluctuations in the sampling air potentially result in erroneous CO2 flux measurements due to cross-sensitivity of the sensor. Here we compare measured CO2 fluxes from both enclosed path Li-Cor 7200 sensors and open-path Li-Cor 7500 instruments from an inland measurement site and a marine site. We also introduce new quality control criteria based upon a Relative Signal Strength Indicator (RSSI). The sampling gas in one of the Li-Cor 7200 instruments was dried by means of a multi-tube diffusion dryer so that the water vapor fluxes were close to zero. With this setup we investigated the effect that cross-sensitivity of the CO2 signal to water vapor can have on the CO2 fluxes. The dryer had no significant effect on the CO2 fluxes. We tested the hypothesis that the cross-sensitivity effect is caused by hygroscopic particles such as sea salt by spraying a saline solution on the windows of the Li-Cor 7200 instruments during the inland field test. Our results confirm earlier findings that sea salt contamination can affect CO2 fluxes significantly and confirm earlier findings, that drying the sampling air for the gas analyzer is an effective method to reduce this signal contamination.
4.	Sayin, Volkan I., 1983, et al. (author) Loss of One Copy of Zfp148 Reduces Lesional Macrophage Proliferation and Atherosclerosis in Mice by Activating p53 2014 In: Circulation Research. - : Ovid Technologies (Wolters Kluwer Health). - 0009-7330 .- 1524-4571. ; 115:9, s. 781-791 Journal article (peer-reviewed)abstract Rationale: Cell proliferation and cell cycle control mechanisms are thought to play central roles in the pathogenesis of atherosclerosis. The transcription factor Zinc finger protein 148 (Zfp148) was shown recently to maintain cell proliferation under oxidative conditions by suppressing p53, a checkpoint protein that arrests proliferation in response to various stressors. It is established that inactivation of p53 accelerates atherosclerosis, but whether increased p53 activation confers protection against the disease remains to be determined. Objective: We aimed to test the hypothesis that Zfp148 deficiency reduces atherosclerosis by unleashing p53 activity. Methods and Results: Mice harboring a gene-trap mutation in the Zfp148 locus (Zfp148(gt/+)) were bred onto the apolipoprotein E (Apoe)(-/-) genetic background and fed a high-fat or chow diet. Loss of 1 copy of Zfp148 markedly reduced atherosclerosis without affecting lipid metabolism. Bone marrow transplantation experiments revealed that the effector cell is of hematopoietic origin. Peritoneal macrophages and atherosclerotic lesions from Zfp148(gt/+)Apoe(-/-) mice showed increased levels of phosphorylated p53 compared with controls, and atherosclerotic lesions contained fewer proliferating macrophages. Zfp148(gt/+) Apoe(-/-) mice were further crossed with p53-null mice (Trp53(-/-) [the gene encoding p53]). There was no difference in atherosclerosis between Zfp148(gt/+) Apoe(-/-) mice and controls on a Trp53(+/-) genetic background, and there was no difference in levels of phosphorylated p53 or cell proliferation. Conclusions: Zfp148 deficiency increases p53 activity and protects against atherosclerosis by causing proliferation arrest of lesional macrophages, suggesting that drugs targeting macrophage proliferation may be useful in the treatment of atherosclerosis.
5.	Baker, Ulrike, et al. (author) Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities : A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework 2018 In: PLOS ONE. - : PUBLIC LIBRARY SCIENCE. - 1932-6203. ; 13:12 Journal article (peer-reviewed)abstract Background: Quality Improvement (OI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect.Materials and methods: A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARI HS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes.Results: Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention's comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge.Conclusion: Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.
6.	Bauer, Brigitte, 1978, et al. (author) Modification and expulsion of keratins by human epidermal keratinocytes upon hapten exposure in vitro. 2011 In: Chemical research in toxicology. - : American Chemical Society (ACS). - 1520-5010 .- 0893-228X. ; 24:5, s. 737-43 Journal article (peer-reviewed)abstract Allergic contact dermatitis is the most prevalent form of human immunotoxicity. It is caused by reactive low molecular weight chemicals, that is, haptens, coming in contact with the skin where hapten-peptide complexes are formed, activating the immune system. By using sensitizing fluorescent thiol-reactive haptens, that is, bromobimanes, we show how keratinocytes respond to hapten exposure in vitro and reveal, for the first time in a living system, an exact site of haptenation. Rapid internalization and reaction of haptens with keratin filaments were visualized. Subsequently, keratinocytes respond in vitro to hapten exposure by release of membrane blebs, which contain haptenated keratins 5 and 14. Particularly, cysteine 54 of K5 was found to be a specific target. A mechanism is proposed where neoepitopes, otherwise hidden from the immune system, are released after hapten exposure via keratinocyte blebbing. The observed expulsion of modified keratins by keratinocytes in vitro might play a role during hapten sensitization in vivo and should be subject to further investigations.
7.	Baumann, Ana A., et al. (author) Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda : a cross-sectional study using the COACH questionnaire 2021 In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:9 Journal article (peer-reviewed)abstract ImportanceHypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary.ObjectiveTo study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool.DesignA cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training.SettingThree tertiary care hospitals in Rwanda.ParticipantsHealthcare professionals (n=223).Primary outcome(s) and measure(s)The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0-1 scale). Four questions surveyed training on hypertension.ResultsResponders (n=223, 75% women; 56% aged 20-35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6 +/- 0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care.ConclusionsThere is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.
8.	Bergström, Anna, 1983-, et al. (author) A facilitated social innovation : stakeholder groups using Plan-Do-Study-Act cycles for perinatal health across levels of the health system in Cao Bang province, Vietnam 2023 In: Implementation Science Communications. - : BioMed Central (BMC). - 2662-2211. ; 4:1 Journal article (peer-reviewed)abstract BackgroundUniversal coverage of evidence-based interventions for perinatal health, often part of evidence-based guidelines, could prevent most perinatal deaths, particularly if entire communities were engaged in the implementation. Social innovations may provide creative solutions to the implementation of evidence-based guidelines, but successful use of social innovations relies on the engagement of communities and health system actors. This proof-of-concept study aimed to assess whether an earlier successful social innovation for improved neonatal survival that employed regular facilitated Plan-Do-Study-Act meetings on the commune level was feasible and acceptable when implemented on multiple levels of the health system (52 health units) and resulted in actions with plausibly favourable effects on perinatal health and survival in Cao Bang province, northern Vietnam.MethodsThe Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided the implementation and evaluation of the Perinatal Knowledge-Into-Practice (PeriKIP) project. Data collection included facilitators’ diaries, health workers’ knowledge on perinatal care, structured observations of antenatal care, focus group discussions with facilitators, their mentors and representatives of different actors of the initiated stakeholder groups and an individual interview with the Reproductive Health Centre director. Clinical experts assessed the relevance of the identified problems and actions taken based on facilitators’ diaries. Descriptive statistics included proportions, means, and t-tests for the knowledge assessment and observations. Qualitative data were analysed by content analysis.ResultsThe social innovation resulted in the identification of about 500 relevant problems. Also, 75% of planned actions to overcome prioritised problems were undertaken, results presented and a plan for new actions to achieve the group’s goals to enhance perinatal health. The facilitators had significant roles, ensuring that the stakeholder groups were established based on principles of mutual respect. Overall, the knowledge of perinatal health and performance of antenatal care improved over the intervention period.ConclusionsThe establishment of facilitated local stakeholder groups can remedy the need for tailored interventions and grassroots involvement in perinatal health and provide a scalable structure for focused efforts to reduce preventable deaths and promote health and well-being.
9.	Bergström, Anna, 1983-, et al. (author) Knowledge about Sexual and Reproductive Health among School Enrolled Adolescents in Tololar, Nicaragua, A Cross-Sectional Study 2018 In: Journal of Public Health International. - : Open Access Pub. - 2641-4538. ; 1:2, s. 27-38 Journal article (peer-reviewed)abstract Background: Nicaragua has the highest prevalence of teenage pregnancies in Latin America. Knowledge regarding sexual and reproductive health plays an integral part in sexual behavior. The objective was to assess school going adolescents' knowledge about sexual and reproductive health and possible factors affecting it in the semi-rural community of Tololar, Nicaragua.Methods: A cross-sectional study with a self-administered questionnaire on tablets was used for data collection. All 253 registered students at the school present at the time of fieldwork who gave written informed consent were deemed eligible for the study. A total of 225 participants in the ages of 11-19 years were included. Simple linear regression and multiple linear regression were performed analyzing the outcome knowledge. A p-value <0.05 was considered significant.Results: The general knowledge about sexual and reproductive health was moderate; however, knowledge gaps were found such as prevailing myths and poor knowledge regarding human immunodeficiency virus (hiv) transmission and contraceptive methods. Being female and single were significant negative determinants of knowledge (p-value < 0.01) and knowledge increased significantly with age (p-value < 0.05). School teachers, websites, social networks, and TV were the most frequently chosen sources of information on the topic.Conclusions: Increased education on sexual and reproductive health with new interventions particularly for young females is recommended. Using IT-based materials as a complement may be an effective way to reach out to adolescents.
10.	Bergström, Anna, 1983-, et al. (author) Knowledge translation in Uganda : a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework 2012 In: Implementation Science. - : BioMed Central (BMC). - 1748-5908. ; 7 Journal article (peer-reviewed)abstract BACKGROUND: A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting.METHODS: This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data.RESULTS: The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT.CONCLUSIONS: In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.
11.	Bergstrøm, Henriette, et al. (author) Psychopathic traits during early childhood : Stable over time or rapidly changing? 2017 Conference paper (other academic/artistic)abstract Although research has shown psychopathic traits to be moderately to highly stable in late childhood and adolescence, little is known about stability in early childhood, specifically in preschool age. The current study was designed to fill this knowledge gap by assessing stability of psychopathic traits in a large community sample (n = 2,121) of three- to five-year-olds (47% girls) across a two-year time span. The sample displayed stable levels of Grandiose-Deceitful (GD), Callous-Unemotional (CU) and Impulsivity, Need for Stimulation (INS) traits. However, the degree of stability varieda cross these three traits dimensions, and by level of analysis, age, and gender. Rank-order stability ranged from low to very high, but effect sizes indicated less stability than on the mean level, where changes were detected but with small effect sizes, thus demonstrating high stability. This trend emerged for both genders, across development, and age. At an individual level, the great majority of the sample displayed stable levels of psychopathic traits to a large extent, with small gender and age differences. The current study is one of the first that investigates stability in children as young as three years old, and it highlights the possibility of measuring psychopathic traits in early childhood.
12.	Bergström, Ida, et al. (author) Annexin A1 in blood mononuclear cells from patients with coronary artery disease : Its association with inflammatory status and glucocorticoid sensitivity 2017 In: PLOS ONE. - : Public Library of Science. - 1932-6203. ; 12:3 Journal article (peer-reviewed)abstract Annexin A1 (AnxA1) is a key player in resolution of inflammation and a mediator of glucocorticoid actions. In atherosclerotic tissue, increased expression of AnxA1 has been associated with protective plaque-stabilizing effects. Here, we investigated the expression of AnxA1 in peripheral blood mononuclear cells (PBMCs) from patients with coronary artery disease (CAD). Blood was collected from 57 patients with stable CAD (SCAD) and 41 healthy controls. We also included a minor group (n = 10) with acute coronary syndrome (ACS). AnxA1 mRNA was measured in PBMCs. Expression of AnxA1 protein (total and surface-bound) and glucocorticoid receptors (GR) were detected in PBMC subsets by flow cytometry. Also, salivary cortisol, interleukin(IL)-6 and IL-10 in plasma, and LPS-induced cytokine secretion from PBMCs, with or without dexamethasone, were assessed. AnxA1 mRNA was found to be slightly increased in PBMCs from SCAD patients compared with controls. However, protein expression of AnxA1 or GRs in PBMC subsets did not differ between SCAD patients and controls, despite SCAD patients showing a more proinflammatory cytokine profile ex vivo. Only surface expression of AnxA1 on monocytes correlated with dexamethasone-mediated suppression of cytokines. In ACS patients, a marked activation of AnxA1 was seen involving both gene expression and translocation of protein to cell surface probably reflecting a rapid glucocorticoid action modulating the acute inflammatory response in ACS. To conclude, surface expression of AnxA1 on monocytes may reflect the degree of glucocorticoid sensitivity. Speculatively, "normal" surface expression of AnxA1 indicates that anti-inflammatory capacity is impaired in SCAD patients.
13.	Blacklock, Claire, et al. (author) Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa : Review of Randomised Clinical Trials 2016 In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 11:1 Journal article (peer-reviewed)abstract BACKGROUND: Africa bears 24% of the global burden of disease but has only 3% of the world's health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.METHODS AND FINDINGS: A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions' components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.CONCLUSIONS: Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.
14.	Boene, Helena, et al. (author) Obstetric fistula in southern Mozambique : a qualitative study on women’s experiences of care pregnancy, delivery and post-partum 2020 In: Reproductive Health. - : Springer Science and Business Media LLC. - 1742-4755. ; 17 Journal article (peer-reviewed)abstract Background: Obstetric fistula is still common in low- and middle-income countries (LMIC) despite the on-going shift to increased facility deliveries in the same settings. The social behavioural circumstances in which fistula, as well as its consequences, still occur are poorly documented, particularly from the perspective of the experiences of women with obstetric fistula. This study sought to describe women’s experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula in order to understand the care-seeking and care provision circumstances which could have been modified to avoid or mitigate the onset or consequences of fistula.Methods: This study took place in Maputo and Gaza provinces, southern Mozambique, in 2016–2017. Qualitative data were collected through in-depth interviews conducted with 14 women with positive diagnoses of fistula and an equal number of women without fistula. All interviews were audio-recorded and transcribed verbatim prior to thematic analysis using NVivo11.Results: Study participants had all attended antenatal care (ANC) visits and had prepared for a facility birth. Prolonged or obstructed labour, multiple referrals, and delays in receiving secondary and tertiary health care were common among the discourses of women with fistula. The term “fistula” was rarely known among participants, but the condition (referred to as “loss of water” or “illness of spillage”) was recognised after being prompted on its signs and symptoms. Women with fistula were invariably aware of the links between fistula and poor birth assistance, in contrast with those without fistula, who blamed the condition on women’s physiological and behavioural characteristics.Conclusion: Although women do seek antenatal and peri-partum care in health facilities, deficiencies and delays in birth assistance, referral and life-saving interventions were commonly reported by women with fistula. Furthermore, weaknesses in quality of care, not only in relation to prevention, but also the resolution of the damage, were evident. Quality improvement of birth care is necessary, both at primary and referral level. There is a need to increase awareness and develop guidelines for prevention, early detection and management of obstetric fistula, including early postpartum treatment, availability of fistula repair for complex cases, and rehabilitation, coupled with the promotion of community consciousness of the problem.
15.	Brunell, Olivia, et al. (author) Effect of a perinatal care quality improvement package on patient satisfaction : a secondary outcome analysis of a cluster-randomised controlled trial 2022 In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 12:6 Journal article (peer-reviewed)abstract Objective To investigate the effect of a quality improvement (QI) package on patient satisfaction of perinatal care. Design Secondary analysis of a stepped-wedge cluster-randomised controlled trial. Participating hospitals were randomised by size into four different wedges. Setting 12 secondary-level public hospitals in Nepal. Participants Women who gave birth in the hospitals at a gestational age of 22 weeks, with fetal heart sound at admission. Adverse outcomes were excluded. One hospital was excluded due to data incompleteness and four low-volume hospitals due to large heterogeneity. The final analysis included 54 919 women. Intervention Hospital management was engaged and facilitators were recruited from within hospitals. Available perinatal care was assessed in each hospital, followed by a bottle-neck analysis workshop. A 3-day training in essential newborn care was carried out for health workers involved in perinatal care, and a set of QI tools were introduced to be used in everyday practice (skill-checks, self-assessment checklists, scoreboards and weekly Plan-Do-Study-Act meetings). Refresher training after 6 months. Outcome measure Women's satisfaction with care during childbirth (a prespecified secondary outcome). Results The likelihood of women being overall satisfied with care during childbirth increased after the intervention (adjusted OR (aOR): 1.66, 95% CI: 1.59 to 1.73). However, the proportions of overall satisfaction were low (control 58%, intervention 62%). Women were more likely to be satisfied with education and information from health workers after intervention (aOR: 1.34, 95% CI: 1.29 to 1.40) and to have been treated with dignity and respect (aOR: 1.81, 95% CI: 1.52 to 2.16). The likelihood of having experienced abuse during the hospital stay decreased (aOR: 0.42, 95% CI: 0.34 to 0.51) and of being satisfied with the level of privacy increased (aOR: 1.14,95% CI: 1.09 to 1.18). Conclusions Improvements in patient satisfaction were indicated after the introduction of a 01-package on perinatal care. We recommend further studies on which aspects of care are most important to improve women's satisfaction of perinatal care in hospitals in Nepal.
16.	Brunell, Olivia, et al. (author) Exploration of factors affecting parent-infant closeness and separation in hospitals in Nepal : a qualitative study Other publication (other academic/artistic)abstract Aim: Closeness is crucial for the physical, emotional and social well-being of both parent and child. Though the benefits of closeness are proven for stable and unstable newborns, separation often remains standard, especially for small or sick newborns. We aimed to explore factors affecting closeness and separation of parents and newborns in hospitals in Nepal. Method: A qualitative design was used. Data was collected by individual interviews with 10 health care workers from labor rooms, post-natal wards or sick newborn care units/neonatal intensive care units, in five referral hospitals in Nepal. Data was analyzed using an inductive thematic approach. Results: Three main themes were generated, 1) Hospital resources, 2) In-hospital practices and attitudes, and 3) Parental-newborn relationships and social factors. Keeping the newborns spatially close to their mothers, offering a comfortable environment, and privacy were thought to enhance closeness, while heavy workload and lack of workforce hampered efforts to enhance closeness. Routines and rules separated parents and newborns, while actions and attitudes among health care workers strengthened closeness. Parental involvement, and the influence of various social aspects such as education, cultural beliefs and gender discrimination, were discussed.Conclusion: Though closeness was considered important, separation was common due to limited resources and existing rules and routines in the hospitals. Introducing small, low-cost changes in the wards, like offering a comfortable place to sit, can help keep the parents close and lessen the workload for health care workers. To avoid separation, hospital rules and practices should be changed, and the parents should be supported to take on the role of primary caregivers, with medical support from health care workers. There are traditions and cultural beliefs in society that hampers parental-infant closeness and gender discrimination remains a problem.
17.	Brunell, Olivia (author) Improving neonatal health care in Nepal 2022 Doctoral thesis (other academic/artistic)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.
18.	Duc, Duong M., 1984-, et al. (author) Measuring local healthcare context for knowledge translation in primary and secondary levels of care in northern Vietnam: A cross-sectional study Other publication (other academic/artistic)abstract BackgroundThe influence of context in shaping the effectiveness of knowledge translation (KT) is widely recognized. The Context Assessment for Community Health (COACH) tool aims to assess contextual aspects that are of importance for KT in healthcare in low- and middle-income settings. This study used the COACH tool to describe healthcare context as perceived by health workers in primary and secondary levels of care in a northern province in Vietnam and to further evaluate the internal structure of the COACH tool.MethodsThis cross-sectional study administered the COACH tool to 677 eligible health workers in primary and secondary levels of care. The relationships between individual background variables and COACH dimensions were analysed using binary logistic regression. Further, internal construct validity was calculated by a first-order independent cluster model confirmatory factor analysis (CFA).ResultsOverall, the healthcare context was perceived as supportive for KT. Gender, age, and geographic location showed significant relationships to one of the COACH dimensions. Male health workers rated their Commitment to work as lower than female health workers (OR=0.39, 95% CI: 0.20–0.78). There were, however, only minor differences in scores for the dimensions of context, at each health facility as well as between health facilities. The CFA asserted an acceptable internal structure of the COACH tool.ConclusionsThe survey enhanced the understanding of how aspects of the healthcare context for KT are perceived by health workers at primary and secondary levels of care in a province in Vietnam. There was an overall positive perception of the work context with only minor variability, reflecting a ‘receptive to change’ context for KT. This should, however, be interpreted with caution due to the risk of social desirability response bias. The findings on the acceptable internal structure of the COACH tool supports its further use as a valid instrument.
19.	Duc, Duong M., 1984-, et al. (author) Response process and test-retest reliability of the Context Assessment for Community Health tool in Vietnam 2016 In: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 9 Journal article (peer-reviewed)abstract Background: The recently developed Context Assessment for Community Health (COACH) tool aims to measure aspects of the local healthcare context perceived to influence knowledge translation in low-and middle-income countries. The tool measures eight dimensions (organizational resources, community engagement, monitoring services for action, sources of knowledge, commitment to work, work culture, leadership, and informal payment) through 49 items. Objective: The study aimed to explore the understanding and stability of the COACH tool among health providers in Vietnam. Designs: To investigate the response process, think-aloud interviews were undertaken with five community health workers, six nurses and midwives, and five physicians. Identified problems were classified according to Conrad and Blair's taxonomy and grouped according to an estimation of the magnitude of the problem's effect on the response data. Further, the stability of the tool was examined using a test-retest survey among 77 respondents. The reliability was analyzed for items (intraclass correlation coefficient (ICC) and percent agreement) and dimensions (ICC and Bland-Altman plots). Results: In general, the think-aloud interviews revealed that the COACH tool was perceived as clear, well organized, and easy to answer. Most items were understood as intended. However, seven prominent problems in the items were identified and the content of three dimensions was perceived to be of a sensitive nature. In the test-retest survey, two-thirds of the items and seven of eight dimensions were found to have an ICC agreement ranging from moderate to substantial (0.5-0.7), demonstrating that the instrument has an acceptable level of stability. Conclusions: This study provides evidence that the Vietnamese translation of the COACH tool is generally perceived to be clear and easy to understand and has acceptable stability. There is, however, a need to rephrase and add generic examples to clarify some items and to further review items with low ICC.
20.	Eriksson, Leif, 1971-, et al. (author) Secular trend, seasonality and effects of a community-based intervention on neonatal mortality : follow-up of a cluster-randomised trial in Quang Ninh province, Vietnam 2018 In: Journal of Epidemiology and Community Health. - : BMJ. - 0143-005X .- 1470-2738. ; 72:9, s. 776-782 Journal article (peer-reviewed)abstract Background: Little is know about whether the effects of community engagement interventions for child survival in low-income and middle-income settings are sustained. Seasonal variation and secular trend may blur the data. Neonatal mortality was reduced in a cluster-randomised trial in Vietnam where laywomen facilitated groups composed of local stakeholders employing a problem-solving approach for 3 years. In this analysis, we aim at disentangling the secular trend, the seasonal variation and the effect of the intervention on neonatal mortality during and after the trial.Methods: In Quang Ninh province, 44 communes were allocated to intervention and 46 to control. Births and neonatal deaths were assessed in a baseline survey in 2005, monitored during the trial in 2008–2011 and followed up by a survey in 2014. Time series analyses were performed on monthly neonatal mortality data.Results: There were 30 187 live births and 480 neonatal deaths. The intervention reduced the neonatal mortality from 19.1 to 11.6 per 1000 live births. The reduction was sustained 3 years after the trial. The control areas reached a similar level at the time of follow-up. Time series decomposition analysis revealed a downward trend in the intervention areas during the trial that was not found in the control areas. Neonatal mortality peaked in the hot and wet summers.Conclusions: A community engagement intervention resulted in a lower neonatal mortality rate that was sustained but not further reduced after the end of the trial. When decomposing time series of neonatal mortality, a clear downward trend was demonstrated in intervention but not in control areas.Trial registration number: ISRCTN44599712, Post-results.
21.	Eriksson, Leif, 1971-, et al. (author) Sustainability of knowledge implementation in a low- and middle- income context : Experiences from a facilitation project in Vietnam targeting maternal and neonatal health 2017 In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 12:8 Journal article (peer-reviewed)abstract BACKGROUND: In a previous trial in Vietnam, a facilitation strategy to secure evidence-based practice in primary care resulted in reduced neonatal mortality over a period of three years. While little is known as to what ensures sustainability in the implementation of community-based strategies, the aim of this study was to investigate factors promoting or hindering implementation, and sustainability of knowledge implementation strategies, by means of the former Neonatal Knowledge Into Practice (NeoKIP) trial.METHODS: In 2014 we targeted all levels in the Vietnamese healthcare system: six individual interviews with representatives at national, provincial and district levels, and six focus group discussions with representatives at the commune level. The interviews were transcribed verbatim, translated to English, and analysed using inductive and deductive thematic analysis.RESULTS: To achieve successful implementation and sustained effect of community-based knowledge implementation strategies, engagement of leaders and key stakeholders at all levels of the healthcare system is vital-prior to, during and after a project. Implementation and sustainability require thorough needs assessment, tailoring of the intervention, and consideration of how to attain and manage funds. The NeoKIP trial was characterised by a high degree of engagement at the primary healthcare system level. Further, three years post trial, maternal and neonatal care was still high on the agenda for healthcare workers and leaders, even though primary aspects such as stakeholder engagement at all levels, and funding had been incomplete or lacking.CONCLUSIONS: The current study illustrates factors to support successful implementation and sustain effects of community-based strategies in projects in low- and middle-income settings; some but not all factors were represented during the post-NeoKIP era. Most importantly, trials in this and similar contexts require deliberate management throughout and beyond the project lifetime, and engagement of key stakeholders, in order to promote and sustain knowledge implementation.
22.	Frogner, Louise, 1983-, et al. (author) Psychopathic Traits During Early Childhood: Stable Over Time or Rapidly Changing? Other publication (other academic/artistic)
23.	Getachew, Theodros, et al. (author) Health extension workers' perceived health system context and health post preparedness to provide services : a cross-sectional study in four Ethiopian regions. 2021 In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:6 Journal article (peer-reviewed)abstract OBJECTIVE: The health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers' perceived context and the preparedness of health posts to provide services.SETTING: This study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019.PARTICIPANTS: A total of 152 health posts and health extension workers serving selected enumeration areas were included.OUTCOME MEASURES: We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool.RESULTS: Internal reliability of COACH was satisfactory. The dimensions community engagement, work culture, commitment to work and leadership all scored high (mean 3.75-4.01 on a 1-5 scale), while organisational resources, sources of knowledge and informal payments scored low (1.78-2.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines.CONCLUSION: The health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia's primary healthcare, provided that they receive improved support, including new information and essential resources.
24.	Holloway, Bronwen, 1982- (author) Acute febrile illness, antibiotic use, and the role of diagnostics to target treatment in India 2022 Doctoral thesis (other academic/artistic)abstract Aim: This thesis examined the causes of acute febrile illness (AFI), the current use of antibiotics and diagnostics, and evaluated the diagnostic accuracy of C-Reactive Protein (CRP) to differentiate bacterial from non-bacterial causes of AFI in children and adult outpatients at R.D. Gardi Medical College hospital, in Ujjain, India. Methods: A prospective cross-sectional study of children and adult outpatients with fever ≥37.5°C, or history of fever in the past 48 hours, and no signs of severe illness. Patient history, physical examination, culture, rapid diagnostic tests, and follow-up after one week was performed for all patients. Whole blood and urine were collected from all patients, and symptom based nasopharyngeal throat swabs, stool, and skin/ear/joint/aspirate specimens. Fever was classified as bacterial or non-bacterial based on microbiology and laboratory results together with an expert panel review. Data on antibiotic use before, during, and after enrolment was described by Anatomical Therapeutic Chemical classification and AWaRe categories. Serum CRP levels were measured and the performance characteristics for CRP to differentiate between bacterial and non-bacterial AFI were calculated. The area under the receiver operating curve (AUC), sensitivity, specificity, positive and negative predictive values, and likelihood ratios were estimated using 10, 20, 40, 60 and 80 mg/L thresholds. A rapid ethnographic qualitative study on the utilization of diagnostics was conducted using unstructured observations, structured observations and 43 semi-structured interviews. Interview data were analyzed using inductive thematic analysis. Results: Of 1000 outpatients, 24.4% were categorized as bacterial; 71.8% non-bacterial; and 3.8% an undetermined cause of fever. Throughout the course of AFI, 41.0% of patients received one or more antibiotics. The leading contributors to total antibiotic volume were macrolides. ‘Watch’ antibiotics accounted for 72.3%, 52.7%, and 32.6% of encounters before, during and after the outpatient visit. The overall median CRP was low but higher in the group classified as bacterial compared to non-bacterial (3.6 mg/L vs. 2.7 mg/L, p<0.0001, respectively). The AUC was low at 0.60 (95% CI 0.56 - 0.65). Caregivers trusted and understood the importance of diagnostics, but their acceptance wavered depending on the severity of illness and preference to treat their child directly with medicines. Caregivers struggled to get tests done and return for follow-up due to costs, delays in testing, further complicated by travel time, distance and competing priorities. Conclusion: This thesis highlights the challenges in determining the cause of AFI. Over,under, and inappropriate use of antibiotics throughout the course of AFI are of major concern.The organization of diagnostic services, together with direct and indirect costs, hinder caregiversfrom utilizing diagnostics. CRP is too weak as a single indicator of bacterial infection to safelysupport physicians in making treatment decisions for febrile outpatients in India.
25.	Holloway, Bronwen, et al. (author) Antibiotic use before, during and after seeking care for acute febrile illness at a hospital outpatient department : a cross-sectional study from rural India 2022 In: Antibiotics. - : MDPI AG. - 2079-6382. ; 11:5 Journal article (peer-reviewed)abstract Antibiotic resistance is a naturally occurring phenomenon, but the misuse and overuse of antibiotics is accelerating the process. This study aimed to quantify and compare antibiotic use before, during, and after seeking outpatient care for acute febrile illness in Ujjain, India. Data were collected through interviews with patients/patient attendants. The prevalence and choice of antibiotics is described by the WHO AWaRe categories and Anatomical Therapeutic Chemical classes, comparing between age groups. Units of measurement include courses, encounters, and Defined Daily Doses (DDDs). The antibiotic prescription during the outpatient visit was also described in relation to the patients’ presumptive diagnosis. Of 1000 included patients, 31.1% (n = 311) received one antibiotic course, 8.1% (n = 81) two, 1.3% (n = 13) three, 0.4% (n = 4) four, 0.1% (n = 1) five, and the remaining 59.0% (n = 590) received no antibiotics. The leading contributors to the total antibiotic volume in the DDDs were macrolides (30.3%), combinations of penicillins, including β-lactamase inhibitors (18.8%), tetracyclines (14.8%), fluoroquinolones (14.6%), and third-generation cephalosporins (13.7%). ‘Watch’ antibiotics accounted for 72.3%, 52.7%, and 64.0% of encounters before, during, and after the outpatient visit, respectively. Acute viral illness accounted for almost half of the total DDDs at the outpatient visit (642.1/1425.3, 45.1%), for which the macrolide antibiotic azithromycin was the most frequently prescribed antibiotic (261.3/642.1, 40.7%).

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