A challenging little balance: How white doulas with mainstream training understand and engage with anti-oppressive practice.

Recent changes in the Estonian education system have been altered in concordance with changes in the socio-cultural context and decision-making processes at the macro, meso and micro levels. The purpose of this study was to investigate teachers’ opinions regarding the education system and its regulations on different decision-making processes at different levels. Forty-five primary school teachers from 28 Estonian schools participated in this study. Semi-structured interviews were carried out, and thematic analysis was used for data analysis. Teachers expressed more negative feelings about not being included in the processes made at the macro level. At the meso level, the teachers were familiar with decisions supporting their professional development. Teachers also mentioned that they should be more recognised in the processes made at the micro level. Teachers need to be more involved in the decision-making processes and in school management to feel that their work is valued. Keywords: Educational system, decision-making processes, primary school teacher, interview

Objective: The Finnish Medicines Agency (Fimea) initiated a programme in 2012 for enhancing interprofessional networking in the medication management of the aged. The goal is to develop national guidelines for interprofessional collaboration with respect to medication management. This study aims to explore the challenges and potential solutions experienced by existing health care teams in managing medication of the aged: (1) at the individual and team level (micro level), (2) organisational level (meso level) and (3) structural level (macro level).Design: Group discussions (n = 10), pair (n = 3) and individual interviews (n = 2). Abductive content analysis combining data and theory was applied. Networking was used as a theoretical framework.Setting: Meetings (n = 15) organised by Fimea in the formation phase of the interprofessional network in 2012.Subjects: Health care professionals (n = 55).Main outcome measures: Challenges and solutions in the medication management of the aged at the micro, meso and macro levels.Results: Challenges in interprofessional collaboration, problems with patient record systems, and the organisation of work and lack of resources were present at all the levels contributing to patients’ medication problems. Participants suggested multiple potential solutions to improve interprofessional collaboration, sharing of tasks and responsibilities, better exploitation of pharmaceutical knowledge and developing tools as being the most commonly mentioned.Conclusions: Optimising medication use of the aged requires new systemic solutions within and between different system levels. The main challenges can be solved by clarifying responsibilities, enhancing communication and applying operational models that involve pharmacists and the use of information technology in medication management.KEY POINTSAn interprofessional team approach has been suggested as a solution to promote rational medicine use among the aged.Fragmented health care system and lack of coordinated patient care are reasons for medication related problems of the aged.Challenges in the implementation of interprofessional collaboration in medication management appear in legislation, information systems, operational models and individuals’ attitudes.Optimising medications requires better interprofessional networking and new systemic solutions within and between macro, meso and micro levels.

BackgroundThere is a need to strengthen interprofessional collaborative practice (IPCP) through interprofessional education (IPE) to improve patient outcomes. To contextualise IPE in primary care, there is a need to understand the factors associated with IPE. This study aims to identify the perceived enablers and barriers of IPE, taking diabetes care as an example, among practising professionals, educators, and institution leaders in primary care.MethodsA qualitative study was conducted in primary care clinics in Singapore. The maximum variation purposive sampling approach was employed and a total of 20 participants were recruited, comprising of 14 healthcare professionals (HCPs), 3 educators, and 3 leaders. Basic demographics data were collected followed by individual semi-structured interviews using a topic guide. Conceptual framework by D'amour and Oandasan was adopted as the underpinning framework to evaluate factors associated to micro (learners and educators), meso (instituitions) and macro (policy and professional bodies) level. Thematic analysis method was adopted for data analysis.ResultsTen themes were identified in this study. For HCPs at the micro level, the themes illustrated interprofessional interactions influenced by learning and work environments, and receptiveness towards IPE shaped by HCPs' attitudes. Additionally, interprofessional collaboration was enhanced through increased interprofessional knowledgeability and overcoming interprofessional hierarchy, while effective communication was fostered by establishing trust, respect, and overcoming psychological barriers. For educators at the micro level, the key themes included the attitudes of educators and the importance of professional development, as well as curriculum development. At the meso level, institutions focused on themes such as resource allocation, system changes, and outcome measurements in the implementation of the IPE programme, along with leadership support for IPE. At the macro level, the emphases were on the roles of policymakers in funding and defining national strategy, as well as the roles of professional bodies in providing educational resources.ConclusionsThis study demonstrated the complexity and interrelation of the factors associated with IPE in primary care. A multi-pronged approach needs to be adopted to address all the barriers in the future implementation of the IPE model in primary care and to design an IPE curriculum that integrates well with clinical practice.Clinical Trial NumberNot Applicable.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

A review of the literature of the (social) representation of Islam, Arabs, and Muslims (collectively, IAM) in the media specifically after 9/11 shows that this topic has attracted growing international attention and has become an ongoing debate among academics in different fields. Indisputably, the discourse of representations has its own complexities. It needs to be addressed in a more inclusive way that examines its various levels to depict the crucial features, especially when a change takes place. Accordingly, this study trails a triangulated analytical model, namely tri-semantic framework, which puts a premium on investigating different levels of discourse and connecting them to the higher level of discourse as well as the overall socio-political changes. In other words, it creates a situational context in order to reveal the ideologies behind the social representations of ‘IAM’. This model draws on different analytical frameworks that can be used for a higher-level analysis, and combines both qualitative and quantitative methods of analysis, as well as a bottom-up analysis to examine texts within their social context. The model incorporates three subtypes of semantics, namely lexical (corpus linguistic features), interpersonal (the appraisal framework, Martin & White, 2005), and attentional (Marchittie, 2003), to reveal and presenting a comprehensive assessment of the ideologies that have operated behind the representations of ‘IAM’ before and after 9/11, from a lexical perspective. Hence, the lexical choices employed by the texts under examination are examined on the micro, meso, and macro levels. On the micro level of discourse, lexical semantic analysis was conducted to examine frequency of lexical choices, collocations, and lexical priming, from a lexical perspective within the framework of Corpus Assisted Discourse Studies (CADS). On the meso level, the APPRAISAL framework was employed to reveal the different attitudes that are implicit in the discourse revealing the ideology of the writers from an interpersonal perspective. Finally, on the macro level, attentional semantics was utilized to examine the linguistic aspects that affected and changed the representations of ‘IAM’ after 9/11 in terms of attention. The analysis was conducted on four different corpuses collected from The Australian and The Age newspapers. The first two corpuses, which functioned as a reference corpus, were compromised of news articles from both newspapers collected during the year preceding 9/11. The second two corpuses, on the other hand, are the target corpuses and they consisted of articles collected after the events of 9/11. An important finding in the current study is that in the discourse under investigation, there were two versions of ideologies operating on two different levels of discourse independently, namely the micro and meso levels, at the same time during both periods of time. In addition, this study argues that the changes of the lexical semantic features on the micro level are ideologically crucial, because the changes that took place on this level was the changes that may have largely influenced the public as a result of being easily recognizable. On the meso level, however, ideological bias is more hidden and needs some further examination to be uncovered by the public; yet, even if it is not recognized, it is always influential. After 9/11, the ideology that operated on the micro level has changed in both newspapers through the employment of a number of significant collocates that indicate the ideology of the newspapers. On the other hand, the ideology on the meso level remained constant, regardless of the increase and decrease in the attitudinal values. However, the socio-political events changed the context of the ideology on this level. In short, as Grewal (2008) suggests, “[t]he meso and micro-levels of analysis help to reinforce the arguments presented in the macro-level analysis” (p. 112). The applicability of the combined method was demonstrated by analyzing the construction of the images of ‘IAM’ in these corpuses, and the discursive function of these images in a socio-political context.

IntroductionGoal setting (GS) is an important aspect of initial spinal cord injury/ disorder (SCI/D) rehabilitation. However, because expected outcomes are individual and often difficult to determine, GS is not straightforward. The aim of this study was to explore the health care professionals' (HCP's) experiences with and perspectives on the goal-setting process (GSP) during initial SCI/D rehabilitation.MethodFive semi-structured focus groups (FG) (22 purposively sampled HCP, mostly in leadership positions, six different professions). The FG were transcribed verbatim. We analyzed the transcripts for qualitative content analysis following Braun and Clarke (2013).ResultsHCP described GS-influencing aspects at the macro, meso and micro levels. At the macro level, participants spoke about restrictions imposed by health insurers or difficulties in planning the post-inpatient setting. Regarding the meso level, HCP spoke of institutional structures and culture that facilitated the GSP. At the micro level, knowledge of the diagnosis, expected outcomes, and individual patient characteristics were mentioned as important to the rehabilitation process. It was important for HCP to be patient and empathetic, to endure negative emotions, to accept that patients need time to adjust to their new situation, and to ensure that they do not lose hope. Open communication and interprofessional collaboration helped overcome barriers in the GSP.DiscussionThis paper shows the complex relationship between external (e.g., health insurers), emotional, and communication aspects. It calls for a comprehensive approach to optimizing the GSP, so that patients' experiences can be fully considered as a basis to identify the most appropriate care pathway.

Background: The Spanish public healthcare system is composed of 17 regional health services managed by the Autonomous Regions. The Autonomous Regions have full management autonomy at structural, organizational and budgetary levels in health and social policies. In the last decade, it became clear that it was needed to rethink the way of responding to the needs of people with one or more chronic conditions, especiallywith older, multimorbid, polymedicated patients and in situations of greater complexity or vulnerability. In 2010, the IEMAC-ARCHO instrument was designed with the purpose of evaluating and re-orienting chronic disease management strategies in various regions. Objective: To describe the evaluation of the chronic care models in the Regional Health Services of Spain during the period 2011-2016. Method: Review of the frequency of use of the IEMAC-ARCHO tool in the different regional health services at the macro, meso and micro levels for the evaluation of plans, programs and strategies of integrated chronic care. IEMAC-ARCHO is the only validated tool that is being used in Spain for evaluation purposes of approaches to chronicity. With 75 items the tool is based on the Chronic Care Model (CCM) and provides a score in all 6 dimensions of the CCM. There are specific versions for diabetes and musculoskeletal conditions. The use of this tool allows to draw the degree of evaluation (and in some way of its deployment) of the strategies or plans of integrated care for chronicity. Results: In the period 2011 to 2016, the IEMAC-ARCHO tool was used in 157 evaluations (14 at the macro level, 78 at the meso level and 65 at the micro level). At the macro level, it has been used by 14/17 (82,3%) of regional health services. At the meso level, 45/78 (57,7%) correspond to evaluations in the Basque Health Service and 8/78 (10,2%) to Andalusia. At the micro level, 28/65 (38,2%) evaluations were performed in Catalonia. The dominant profile of meso-level centers that used IEMAC-ARCHO corresponded to Integrated Care Organizations (ICOs) (42.3%). The highest scored dimension was “The reorganization of Delivery Model” (45 points in average) and the lowest “Community Health” (30 points in average). 14,1% of organizations have evaluated twice or more showing highest improvements in “The reorganization of Delivery Model”, “Self-management Support” and “Information Systems”. Conclusions: The mapping of the self-assessments carried out with IEMAC-ARCHO gives us an overview of the development of new models in relation to chronicity in Spain, which largely corresponds with the development of chronicity plans. The main users of the tool are the vertically integrated organizations, since to a large extent the development of these new organizational forms is linked to new approaches of integrated care for chronicity and to new approaches of population health management. In the Spanish context where evaluation of policies is usually scarce, IEMAC-ARCHO has proven to be a useful tool for systematic evaluation of plans and strategies related to chronicity.

Most shared decision-making (SDM) models within healthcare have been limited to the patient–physician dyad. As a first step towards promoting an interprofessional approach to SDM in primary care, this article reports how an interprofessional and interdisciplinary group developed and achieved consensus on a new interprofessional SDM model. The key concepts within published reviews of SDM models and interprofessionalism were identified, analysed, and discussed by the group in order to reach consensus on the new interprofessional SDM (IP-SDM) model. The IP-SDM model comprises three levels: the individual (micro) level and two healthcare system (meso and macro) levels. At the individual level, the patient presents with a health condition that requires decision-making and follows a structured process to make an informed, value-based decision in concert with a team of healthcare professionals. The model acknowledges (at the meso level) the influence of individual team members' professional roles including the decision coach and organizational routines. At the macro level it acknowledges the influence of system level factors (i.e. health policies, professional organisations, and social context) on the meso and individual levels. Subsequently, the IP-SDM model will be validated with other stakeholders.

Purpose: The present study was conducted with the aim of examining the indicators of barriers and challenges of virtual education at macro, meso, and micro levels. Methods and Materials: The method employed in this research is a mixed-methods approach. In the qualitative section, documents from the Ministry of Education of the Islamic Republic of Iran, including the "Fundamental Theoretical Foundations for Formal and Public Education Transformation," the "Fundamental Transformation Document of Education," and the "National Curriculum Document," were analyzed. In the quantitative section, two non-random sampling methods were used: non-probability sampling and snowball sampling, which is a non-probability sampling method commonly used in sociology and statistical research. The research population consisted of 150 students from Farhangian University and 10 faculty members from the same institution. Interviews were conducted based on a competency model, and the appropriate tool was developed and implemented after determining its validity and reliability using Cronbach's alpha (α = 0.92). Findings: Based on the findings, 150 digital teacher competencies were categorized into 9 sections, which were further divided into three main areas: curriculum design, barriers to virtual education, and the quality of virtual teaching. The challenges identified in the study were categorized at macro, meso, and micro levels, and the results are applicable for identifying the indicators of barriers and challenges in virtual education. Conclusion: The results of the study indicate that, at the macro level, poor policy-making is the primary issue, at the meso level, budget disruptions are prominent, and at the micro level, students, more than parents, teachers, and professors, believe that the barriers and challenges of virtual education are greater than those of in-person education.

Amid a global decline in fertility rates, China's consistently low birth rate has highlighted the importance of understanding the fertility attitudes of women of childbearing age. While previous studies have largely focused on fertility anxiety, less attention has been paid to anti-fertility anxiety-women's psychological resistance to societal pressures and expectations surrounding childbearing. To address this research gap, this study explores how women construct and articulate these seemingly conflicting attitudes, as well as the sociopsychological mechanisms that enable their coexistence. Using grounded theory and natural language processing techniques, the study analyzed 4,495 Weibo posts (fertility anxiety = 2,761; anti-fertility anxiety = 1,734) through three-level coding, semantic network analysis, and sentiment analysis. The findings indicate that both fertility anxiety and anti-fertility anxiety are shaped by sociocultural and media narratives at the macro level, family and workplace dynamics at the meso level, and personal values and experiences at the micro level. Fertility anxiety discourse is primarily situated at the macro and meso levels, reflecting women's feelings of insecurity and powerlessness in the face of societal pressures, maternal penalties and unequal family burdens. Anti-fertility anxiety is more rooted in micro-level expression, emphasizing reproductive autonomy and identification with motherhood amid a broader feminist awakening. The emotional tendency of fertility anxiety is predominantly negative, with intensity decreasing from the macro to the meso and micro levels. Anti-fertility anxiety is associated with more positive emotions, with emotional intensity declining from the micro to the meso and macro levels. This study highlights the psychological tension between structural constraints and subjective desires in women's fertility decisions, reinforcing explanations for conflicting fertility attitudes in the context of social media empowerment. These insights contribute to the conceptual understanding of anti-fertility anxiety and also offer practical recommendations for enhancing women's reproductive autonomy, psychological well-being, and fertility-related policies and support systems.

Introduction. The paper has developed a new scheme of a multimodal logistics system for grain transportation for export to Iran using links and graphs. It is proposed to consider the functioning of road transport in a multimodal logistics system for grain export from the standpoint of a systematic approach at the micro, meso and macro levels based on the newly introduced concept of transport capacity of the simulated graph. To determine the optimal modes of road transport functioning (with the further aim of increasing its efficiency of functioning) in the logistics links of export grain supplies at the micro level, it is proposed to perform using the ‘Sowing fields – regional barn-floors’ graph, at the meso level – the ‘Regional barn-floors – regional grain storages’ graph, at the macro level – the ‘Regional grain storages – port grain storages’ graph. Graphs modelling, determining the transport capacity of vertices, fixing vertices for barn-floors, regional grain storages and port grain storages make it possible for agro–industrial enterprises to plan the volume of grain exports, to use their acreage rationally considering crop yields while fulfilling an important condition - ensuring food security for the population of the Russian Federation. Road transport planning at the micro level is directly linked to the operation of agricultural enterprises, and at the meso level to grain storages. At the macro level, road transport serves the three largest port grain receiving points of the Volgograd region. Multimodal transportation of grain from a specific farm in the region to the port of Enzeli in Iran has been organized using road transport and VOLGO-BALT 239 river-sea vessel.Materials and methods. The paper uses methods of statistical analysis of winter wheat supplies for export to Iran from the Volgograd region. At the micro level, graphoanalytic methods are used to model the location schemes of filling bunkers when working in a team of one, three or nine combines, indicating their number of appearance on the field in the xOy coordinate plane. The methods of system analysis were used to correctly divide the international multimodal logistics system for the transportation of export grain into micro, meso and macro levels with the definition of the place and role of transport. Methods of solving the linear programming problem are the optimization of the assignment of consumers to suppliers at all levels under consideration.Results. It is revealed that complex international multimodal logistics systems for the delivery of export grain must be considered using a systematic approach. It is proposed to consider the system at the micro, meso and macro levels. At each of the levels, it is necessary to plan the operation of transport based on calculations of the ‘transport capacity’ of the ‘Sowing fields – regional barn-floors’, ‘Regional barn-floors – regional grain storages’, ‘Regional grain storages – port grain storages’ graph nodes. OOO Progress, the agro-enterprise of the Volgograd region, has been given the opportunity to plan its work taking into account new information technologies that ensure higher efficiency of agricultural activities in the cultivation of winter wheat with partial sale for export to Iran.Discussion and conclusions. The improvement of the organisation of road transport functioning in the international multimodal logistics system of grain export supplies cannot exist without the use of precision farming technologies in harvesting and transport processes. The use of the right logistics technologies in road transport and in the organisation of winter wheat cultivation has a great impact on the final cost of grain and on the guaranteed food security of the Russian Federation. Research in this direction is currently relevant.

(1) Background and objective: to explore the experiences of Swiss health care providers involved in a community fall prevention pilot project on barriers and facilitations in interprofessional cooperation between 2016 and 2017 in three regions of Switzerland. (2) Methods: semi-structured interviews with health care providers assessed their perspective on the evaluation of jointly developed tools for reporting fall risk, continuous training of the health care providers, sensitizing media campaigns, and others. (3) Results: One of the project’s strengths is the interprofessional continuous trainings. These trainings allowed the health care providers to extend their network of health care providers, which contributed to an improvement of fall prevention. Challenges of the project were that the standardization of the interprofessional collaboration required additional efforts. These efforts are time consuming and, for some categories of health care providers, not remunerated by the Swiss health care system. (4) Conclusions: On a micro and meso level, the results of the present study indicate that the involved health care providers strongly support interprofessional collaboration in fall prevention. However, time and financial constraints challenge the implementation. On a macro level, potential ways to strengthen interprofessional collaboration are a core element in fall prevention.

to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. Identification of these barriers and facilitators is expected to promote better and more appropriate care. For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).

Health services and public health researchers provide timely and critical evidence to answer real-world policy questions and work extensively with policymakers at the macro, meso and micro levels of government. One goal shared by researchers and policymakers is to foster evidence-informed policy and program development to ensure that policy initiatives provide the greatest benefit possible to individuals and society. Among other sources of data, meso-level datasets are usually comprising contextual data aggregated at various geographical areas such as cities, counties, and regions. Although meso-level data are sometimes used as proxies for individual level data, they can also be used to explore complex questions at the population level. This workshop aims to provide a unique, interprofessional, European conversation about how to translate meso-level research evidence into meaningful insights or recommendations. It brings together a group of high-level people from academia, think tanks, and companies who are involved in generating, transferring, or using meso-level evidence to inform public health and health care policy in Germany and France. In the first presentation, Schüttig et al. use district-level data from Germany to suggest that increased spending and improved continuity of care may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes. Then, Mercier et al. analyze department (district)-level data from France to quantify the impact of the population-based prevalence of diabetes and psychiatric conditions, of air pollution, of socio-economic variables, and of meteorological factors on the spread of COVID-19 during the first lockdown. Rodts et al, in a collaboration between a think tank and a small company, use a broad set of district-level variables to classify French ‘departements’ into homogeneous clusters in terms in needs and explore the discrepancies between total health care spending and needs at the population level. Finally, Mâlatre-Lansac et al. build on these studies to discuss how data can be used to inform public health and health care policy making in Europe. In addition, they suggest future directions to improve meso-level data-driven policy at the local, national, and European levels. Beyond methodological points, the discussion will address ethical issues in the use of meso-level data, and how to improve the availability of data, and the ability of local, regional, and national policymakers to use research evidence efficiently. It is designed as a regular workshop with 4 presentations (10 minutes each), ample audience interaction through Q&A after each presentation and one freehand poll in the introduction of each presentation.Key messages• Meso-level data can be efficiently leveraged to inform health care policy.• Further efforts need to be taken to address the information needs of policymakers.

BackgroundConceptualization of quality of care – in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study.MethodsThis cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011–2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics).ResultsThe three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. ‘Quality’ in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided.ConclusionThe quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.