Barriers to the early initiation of antenatal care: a qualitative study of women and service providers in East London

In the UK, guidelines for antenatal care recommend that women receive their first antenatal appointment as early as possible within the first trimester of pregnancy. However, many women have their first antenatal care appointment later than 12 weeks of pregnancy. Research on the barriers to early initiation of antenatal care has mainly focused on identifying socio-demographic predictors of late initiation, rather than exploring women’s perspectives on and experiences of pregnancy and antenatal care, and the qualitative research that has been conducted in the field has been largely confined to North America. In 2010-11, as part of a mixed methods study funded by the National Institute for Health Research (NIHR), we conducted qualitative research which explored the barriers to early initiation and continued attendance for antenatal care. The research involved 21 in-depth interviews and five focus groups with an ethnically diverse sample of women living in East London and two focus groups with staff of the NHS. The study identified a range of barriers to early initiation of antenatal care, which both individually and cumulatively result in delayed initiation of antenatal care services; including the perception that antenatal care is only to be initiated for viable and continuing pregnancies, little perceived urgency in initiating antenatal care (particularly if previous pregnancies have been uncomplicated), as well as difficulties accessing referrals to antenatal care and service provider delays in the processing of referrals. Early initiation, continued attendance and satisfaction with antenatal care were found to be influenced by appointment scheduling and waiting times, the nature of interpersonal interactions with staff, and the availability of interpreters for those with limited English. Women from different cultural communities were also found to conceptualise pregnancy in different ways, which may affect engagement with antenatal care services. To improve early initiation of and experiences of antenatal care, we suggest that a complex intervention package needs to be developed and evaluated within ethnically diverse contexts, which addresses the multiple barriers identified by our research regarding perceptions of the purpose, value and nature of antenatal care, and factors within maternity service organisation, which may delay early initiation of antenatal care

Causes of tuberculosis stigma in South Asia: developing explanatory theories through multi-country qualitative research

Although tuberculosis (TB) stigma has been widely reported in South Asia and elsewhere, few interventions have been introduced to reduce it. Whilst it is recognised that stigma interventions need to address the fundamental causes of stigma and that their design needs to be theory-driven, causal theories to explain TB stigma are lacking. In this thesis I present the development of causal theories to explain manifestations of TB stigma and identify theory-driven approaches to addressing TB stigma in South Asia. Causal theories to explain TB stigma were developed using a multi-country comparative approach, involving qualitative methods and the principles of grounded theory, alongside a realist conceptualisation of causality. Qualitative data was collected through 73 interviews with people with TB, their family members and health care providers in three rural and two urban sites in Bangladesh, Nepal and Pakistan, and through eight focus group discussions conducted in three of the sites. Three manifestations of TB stigma, for which causal theories were developed, were identified from the data: reduced marriage prospects, the perception that people with TB are hated, and the attribution of blame for the course and reoccurrence of TB. All three manifestations are rooted in different psychological processes and it is between these manifestations and their roots that the realist causal theories lie. The mechanisms and contexts which explain how, for whom and in what circumstances TB stigma becomes manifest provide the theory that can be used to underpin approaches to addressing TB stigma. These approaches focus on influencing the legitimacy of rejection, hatred and blame, on reducing vulnerability to TB, on empowering people with TB, and on mainstreaming TB stigma and pre-empting the changing nature of its manifestations

Load prediction based remaining discharge energy estimation using a combined online and offline prediction framework

Remaining discharge energy (RDE) indicates how much useful energy can be extracted from a battery before reaching the discharge limit. Future current loading on vehicle battery systems can be predicted to increase the accuracy of RDE estimations. This is done by using clustering techniques to group load measurements into states, and then using a probability-based framework, along with real-world data, to calculate the transitional probabilities between states. Here, an adapted K-means clustering method is used to cluster load profile data. Markov modelling is used to produce state transition probabilities. Two methods for load prediction are used, which are referred to as the offline-training method and the moving window method, where the offline-training method has not been implemented for this application before. Additional control logic is implemented to combine the proposed load prediction methods to produce a new hybrid load prediction method. This hybrid method shows improved RDE accuracy for a generalised load case. The robustness of the proposed technique is assessed in the presence of model errors, still showing good accuracy when compared to state-of-charge based calculations

Remaining discharge energy estimation for lithium-ion batteries using pattern recognition and power prediction

The remaining discharge energy (RDE) of a battery is an important value for estimating the remaining range of a vehicle. Prediction based methods for calculating RDE have been proven to be suitable for improving energy estimation accuracy. This paper aims to further improve the estimation accuracy by incorporating novel load prediction techniques with pattern recognition into the RDE calculation. For the pattern recognition, driving segment data was categorised into different usage patterns, then a rule-based logic was designed to recognise these, based on features from each pattern. For the power prediction, a clustering and Markov modelling approach was used to group and define power levels from the data as states and find the probabilities of each state-to-state transition occurring. This data was defined for each pattern, so that the logic could inform what data should be used to predict the future power profile. From the predicted power profile, the RDE was calculated from the product of the predicted load and the predicted voltage, which was obtained from a first-order battery model. The proposed algorithm was tested in simulation and real-time using battery cycler data, and compared against other prediction-based methods. The proposed method was shown to have desirable accuracy and robustness to modelling errors. The primary conclusion from this research was using pattern recognition can improve the accuracy of RDE estimation

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB’s negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB’s disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies

Young women and limits to the normalisation of condom use: a qualitative study

Encouraging condom use among young women is a major focus of HIV/STI prevention efforts but the degree to which they see themselves as being at risk limits their use of the method. In this paper, we examine the extent to which condom use has become normalised among young women. In-depth interviews were conducted with 20 year old women from eastern Scotland (N = 20). Purposive sampling was used to select a heterogeneous group with different levels of sexual experience and from different social backgrounds. All of the interviewees had used (male) condoms but only three reported consistent use. The rest had changed to other methods, most often the pill, though they typically went back to using condoms occasionally. Condoms were talked about as the most readily available contraceptive method, and were most often the first contraceptive method used. The young women had ingrained expectations of use, but for most, these norms centred only on their new or casual partners, with whom not using condoms was thought to be irresponsible. Many reported negative experiences with condoms, and condom dislike and failure were common, lessening trust in the method. Although the sexually transmitted infection (STI) prevention provided by condoms was important, this was seen as additional, and secondary, to pregnancy prevention. As the perceived risks of STIs lessened in relationships with boyfriends, so did condom use. The promotion of condoms for STI prevention alone fails to consider the wider influences of partners and young women's negative experiences of the method. Focusing on the development of condom negotiation skills alone will not address these issues. Interventions to counter dislike, method failure, and the limits of the normalisation of condom use should be included in STI prevention efforts

Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK

Background: In the UK, women are recommended to engage with maternity services and establish a plan of care prior to the 12th completed week of pregnancy. The aim of this study was to identify predictors for late initiation of antenatal care within an ethnically diverse cohort in East London. Methods: Cross-sectional analysis of routinely collected electronic patient record data from Newham University Hospital NHS Trust (NUHT). All women who attended their antenatal booking appointment within NUHT between 1st January 2008 and 24th January 2011 were included in this study. The main outcome measure was late antenatal booking, defined as attendance at the antenatal booking appointment after 12 weeks (+6 days) gestation. Data were analysed using multivariable logistic regression with robust standard errors. Results: Late initiation of antenatal care was independently associated with non-British (White) ethnicity, inability to speak English, and non-UK maternal birthplace in the multivariable model. However, among those women who both spoke English and were born in the UK, the only ethnic group at increased risk of late booking were women who identified as African/Caribbean (aOR: 1.40: 95% CI: 1.11, 1.76) relative to British (White). Other predictors identified include maternal age younger than 20 years (aOR: 1.32; 95% CI: 1.13-1.54), high parity (aOR: 2.09; 95% CI: 1.77-2.46) and living in temporary accommodation (aOR: 1.71; 95% CI: 1.35-2.16). Conclusions: Socio-cultural factors in addition to poor English ability or assimilation may play an important role in determining early initiation of antenatal care. Future research should focus on effective interventions to encourage and enable these minority groups to engage with the maternity services

Timing of the initiation of antenatal care: An exploratory qualitative study of women and service providers in East London

Objective to explore the factors which influence the timing of the initiation of a package of publically-funded antenatal care for pregnant women living in a diverse urban setting Design a qualitative study involving thematic analysis of 21 individual interviews and six focus group discussions. Setting Newham, a culturally diverse borough in East London, UK Participants individual interviews were conducted with 21 pregnant and postnatal women and focus group discussions were conducted with a total of 26 health service staff members(midwives and bilingual health advocates) and 32 women from four community groups (Bangladeshi, Somali, Lithuanian and Polish). Findings initial care-seeking by pregnant women is influenced by the perception that the package of antenatal care offered by the National Health Service is for viable and continuing pregnancies, as well as little perceived urgency in initiating antenatal care. This is particularly true when set against competing responsibilities and commitments in women’s lives and for pregnancies with no apparent complications or disconcerting symptoms. Barriers to access to this package of antenatal care include difficulties in navigating the health service and referral system, which are compounded for women unable to speak English, and service provider delays in the processing of referrals. Accessing antenatal care was sometimes equated with relinquishing control, particularly for young women and women for whom language barriers prohibit active engagement with care. Conclusions and implications for practice if women are to be encouraged to seek antenatal care from maternity services early in pregnancy, the purpose and value to all women of doing so need to be made clear across the communities in which they live. As a woman may need time to accept her pregnancy and address other priorities in her life before seeking antenatal care, it is crucial that once she does decide to seek such care, access is quick and easy. Difficulties found in navigating the system of referral for antenatal care point to a need for improved access to primary care and a simple and efficient process of direct referral to antenatal care, alongside the delivery of antenatal care which is woman-centred and experienced as empowering