There are advantages and disadvantages to using Qualitative Data, as data is very rich in nature so a collection of this type of data is very useful for many cases, but there are some disadvantages of it as well. Let’s dive into the advantages and disadvantages of Qualitative Data in detail.
Some advantages of Qualitative Data are as follows:
Some disadvantages of Qualitative Data are as follows:
Question 1: To which category, the game data for the game “name, place animal or thing” will belong?
Qualitative data will be used to illustrate the type of data used to represent the names for the places, animals, things.
Question 2: Which type of data is used by the evaluator to grade the students using a range of marks?
The marks are expressed in the range, or using perfect integrals. Ordinal data is used to represent the range of data distribution used by the evaluator.
Question 3: The following table depicts the percentage of people who prefer a certain movie genre. Can you represent this categorical data using a pie chart?
Sports | Percentage of Students |
---|---|
| |
| |
|
Sports Percentage of students Calculation of Angle [Angle = (Percentage / 100) x 360°] Angle Cricket 25% Angle = (25/100) x 360° 90° Table Tennis 35% Angle = (35/100) x 360° 126° Football 40% Angle = (40/100) x 360° 144° Thus, pie chart of the given qualitative data is as follows:
Question 4: The following bar graph depicts the ordinal categorical data of the mobile phone company according to price range.
Answer the following questions according to the bar graph
Based on the observations made from the bar graph: Total number of students = 30k + 55k + 45k = 130k Average of the price of all the Phones = (30 + 55 + 45)/3 = 130/3 = 46.67 k
Qualitative data is a type of non-numeric information that categorizes and describes various things, making it easier to find patterns and trends. It’s critical for examining a community’s behavior, tastes, and features. For instance, insights can be gained when qualitative analyses are done on data classified into nominal or ordinal categories. This method has gained popularity in areas such as marketing research and social sciences.
What is qualitative or categorical data.
Qualitative data is the non-numerical data which describes the qualities, characteristics, and other descriptive information about the phenomenon or the subject for which data is collected.
Some examples of qualitative data include survey forms of interviews or focus groups, observational notes, photographs, and other forms of non-numerical data.
Qualitative Data is often collected through observation, interviews, focus groups, and other forms of subjective data collection methods .
Qualitative data is typically analyzed using two approaches which are covered in detail in this article. Deductive Approach Inductive Approach
Some advantages of use of qualitative data are: Qualitative data provides in-depth information about a subject or phenomenon. It can also provide rich descriptions of the context and social interactions surrounding the subject or phenomenon. Qualitative data can be more flexible in terms of data collection and analysis methods, allowing for more creative and iterative approaches to research.
Some disadvantages of use of qualitative data are: Qualitative data can be time-consuming and resource-intensive to collect and analyze. As qualitative data is subjective and interpretive, there may be concerns about the reliability and validity of the data. Qualitative data may also be less generalizable than quantitative data, as it is often focused on specific contexts and perspectives.
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Reflexivity in qualitative research is defined as the practice of self-awareness and critical examination of the researcher’s influence on the research process. It involves acknowledging and addressing the researcher’s positionality, biases, values, and experiences that may shape the study’s design, data collection, and interpretation. Reflexivity is grounded in the understanding that researchers are not neutral observers but actively contribute to the construction of knowledge through their interactions with participants and engagement with the data.
The first aspect of reflexivity involves recognizing the researcher’s subjectivity and the potential impact of their background, beliefs, and experiences on the research. Researchers bring their own perspectives to the study, influencing everything from the formulation of research questions to the interpretation of findings. By acknowledging this subjectivity, researchers can take steps to minimize bias and enhance the transparency and validity of their research.
Secondly, reflexivity prompts researchers to document and critically reflect on their decision-making processes throughout the research journey. This includes considerations of how personal beliefs and experiences may shape the framing of questions during interviews, the selection of participants, and the interpretation of data. Maintaining a reflexive journal or diary allows researchers to capture insights into their evolving awareness and potential biases.
Furthermore, reflexivity encourages an ongoing dialogue between the researcher and the data. As researchers engage with participants and analyze qualitative data, they continuously reflect on how their own perspectives may influence the interpretation of findings. This iterative process enables a deeper understanding of the complex dynamics at play and allows for adjustments in the research approach as needed.
Reflexivity in qualitative research encompasses several key characteristics that highlight the self-awareness and critical reflection of the researcher throughout the research process. These characteristics contribute to the transparency, rigor, and ethical conduct of qualitative studies:
These characteristics collectively underscore the importance of reflexivity as an integral part of qualitative research, ensuring that researchers navigate their own subjectivity with transparency and diligence.
Reflexivity plays a crucial role in qualitative research and holds significant importance for several reasons. It contributes to the transparency, rigor, and ethical conduct of the research process, ultimately enhancing the credibility and trustworthiness of study findings. Here are key reasons highlighting the importance of reflexivity in qualitative research:
Applying reflexivity in qualitative research involves integrating self-awareness, critical reflection, and transparency into the research process. Here are some best practices to effectively incorporate reflexivity into qualitative research:
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Descriptive research is a methodological approach that seeks to depict the characteristics of a phenomenon or subject under investigation. In scientific inquiry, it serves as a foundational tool for researchers aiming to observe, record, and analyze the intricate details of a particular topic. This method provides a rich and detailed account that aids in understanding, categorizing, and interpreting the subject matter.
Descriptive research design is widely employed across diverse fields, and its primary objective is to systematically observe and document all variables and conditions influencing the phenomenon.
After this descriptive research definition, let’s look at this example. Consider a researcher working on climate change adaptation, who wants to understand water management trends in an arid village in a specific study area. She must conduct a demographic survey of the region, gather population data, and then conduct descriptive research on this demographic segment. The study will then uncover details on “what are the water management practices and trends in village X.” Note, however, that it will not cover any investigative information about “why” the patterns exist.
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If you’ve been wondering “What is descriptive research,” we’ve got you covered in this post! In a nutshell, descriptive research is an exploratory research method that helps a researcher describe a population, circumstance, or phenomenon. It can help answer what , where , when and how questions, but not why questions. In other words, it does not involve changing the study variables and does not seek to establish cause-and-effect relationships.
Now, let’s delve into the importance of descriptive research. This research method acts as the cornerstone for various academic and applied disciplines. Its primary significance lies in its ability to provide a comprehensive overview of a phenomenon, enabling researchers to gain a nuanced understanding of the variables at play. This method aids in forming hypotheses, generating insights, and laying the groundwork for further in-depth investigations. The following points further illustrate its importance:
Provides insights into a population or phenomenon: Descriptive research furnishes a comprehensive overview of the characteristics and behaviors of a specific population or phenomenon, thereby guiding and shaping the research project.
Offers baseline data: The data acquired through this type of research acts as a reference for subsequent investigations, laying the groundwork for further studies.
Allows validation of sampling methods: Descriptive research validates sampling methods, aiding in the selection of the most effective approach for the study.
Helps reduce time and costs: It is cost-effective and time-efficient, making this an economical means of gathering information about a specific population or phenomenon.
Ensures replicability: Descriptive research is easily replicable, ensuring a reliable way to collect and compare information from various sources.
Determining when to use descriptive research depends on the nature of the research question. Before diving into the reasons behind an occurrence, understanding the how, when, and where aspects is essential. Descriptive research design is a suitable option when the research objective is to discern characteristics, frequencies, trends, and categories without manipulating variables. It is therefore often employed in the initial stages of a study before progressing to more complex research designs. To put it in another way, descriptive research precedes the hypotheses of explanatory research. It is particularly valuable when there is limited existing knowledge about the subject.
Some examples are as follows, highlighting that these questions would arise before a clear outline of the research plan is established:
Coming to the characteristics of descriptive research, this approach is characterized by its focus on observing and documenting the features of a subject. Specific characteristics are as below.
There are various descriptive research types, each suited to different research objectives. Take a look at the different types below.
Several descriptive research methods can be employed, and these are more or less similar to the types of approaches mentioned above.
Researchers must carefully consider descriptive research methods, types, and examples to harness their full potential in contributing to scientific knowledge.
Now, let’s consider some descriptive research examples.
These examples showcase the versatility of descriptive research across diverse fields.
There are several advantages to this approach, which every researcher must be aware of. These are as follows:
On the other hand, this design has some drawbacks as well:
To reiterate, the advantages of descriptive research lie in its ability to provide a comprehensive overview, aid hypothesis generation, and serve as a preliminary step in the research process. However, its limitations include a potential lack of depth, inability to establish cause-and-effect relationships, and susceptibility to bias.
When should researchers conduct descriptive research.
Descriptive research is most appropriate when researchers aim to portray and understand the characteristics of a phenomenon without manipulating variables. It is particularly valuable in the early stages of a study.
Descriptive research focuses on providing a detailed depiction of a phenomenon, while exploratory research aims to explore and generate insights into an issue where little is known.
Descriptive research observes and documents without manipulating variables, whereas experimental research involves intentional interventions to establish cause-and-effect relationships.
No, various descriptive research types may be applicable to all fields of study, including social science, humanities, physical science, and biological science.
The importance of descriptive research lies in its ability to provide a glimpse of the current state of a phenomenon, offering valuable insights and establishing a basic understanding. Further, the advantages of descriptive research include its capacity to offer a straightforward depiction of a situation or phenomenon, facilitate the identification of patterns or trends, and serve as a useful starting point for more in-depth investigations. Additionally, descriptive research can contribute to the development of hypotheses and guide the formulation of research questions for subsequent studies.
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BMC Women's Health volume 24 , Article number: 477 ( 2024 ) Cite this article
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Multiple sclerosis (MS) is a debilitating, non-traumatic disease that is common among young adults. Cultural factors, as background factors, can affect how patients adapt and their quality of life. This study aimed to explain the burden of cultural factors on Multiple sclerosis.
This study was conducted with a qualitative approach and conventional content analysis among women with Multiple sclerosis in Mashhad. The data were collected through semi-structured interviews with women with MS. Fifteen patients with Multiple sclerosis were selected using purposeful sampling. The Graneheim and Lundman method was used to analyze the collected data. The transferability of the study was evaluated using the Guba and Lincoln criteria. MAXQADA 10 software was used to manage and analyze the data.
In explanation of the cultural factors of patients with Multiple sclerosis, one category (cultural tensions) and five subcategories (forced communication with spouse’s family, definition of women’s role in society, people’s behavior, social beliefs and isolation of the patient) were extracted.
The results obtained in this study show that female MS patients face various concerns. Overcoming these challenges require a change in the attitude of people in the society towards women with MS, which is important in the context of formulating practical policies to create a suitable culture. Adopted policies should aim to internalize the culture of changing society’s views of female MS patients. Therefore, the authors argue that there is a need for cultural policies, followed by the systems implementing these policies to consider the challenges mentioned in this study as a priority for MS patients.
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Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease of the central nervous system (CNS) [ 1 ]. Multiple sclerosis is usually diagnosed between the ages of 20 and 40 [ 2 ]. The prevalence and incidence of MS is expanding worldwide, and the prevalence of MS is estimated to be 35.9 persons per 100,000 population (2.8 million people) in 2020 [ 3 ]. The probability of MS in women is almost to 2–3 times higher than that in men [ 4 , 5 ]. The prevalence of MS in women and men was estimated to be 44.8/ 100,000 and 16.5/ 100,000, respectively [ 6 ].
People suffering from this disease need to deal with and adapt to its everlasting challenges [ 7 ]. Cultural practices and beliefs of patients affect their coping style with challenges. Due to the abundance and complexity of a person’s relationship with the society and its culture, the influence of cultural factors on human behavior cannot be ignored [ 8 ].
Every culture has certain views, behaviors and beliefs that not only affect people’s way of life, roles and their worldviews, but also affect the health and the numerous illnesses that plagues the people in the society [ 9 ]. Cultural differences can influence the concepts of health and diseases of societies and each society creates ways to treat and manage illnesses based on its culture [ 10 ].
The word “culture” refers to systems of knowledge, concepts, rules and activities that are learnable and are passed down from one generation to another [ 11 ].
Culture influences the ways of describing and understanding patients’ experiences and visible behavioral cues in clinical encounters, symptomatology, clinical manifestations, treatment expectations, adaptation to the disease, and treatment responses [ 12 ].
Psychosocial stressors and cultural characteristics may cause problems in communication and affect the diagnosis and treatment [ 13 ]. Sociocultural norms and beliefs lead people in society to have certain expectations based on specific gender roles for women [ 14 ].
For example, the irrational expectations of the spouse’s family and their great influence on the spouse’s decisions has become the basis for more worries in life [ 15 ]. Studies show that the main notions of the way of doing the housework have not changed much for men and women. They also show that housework and taking care of children are still considered the main duties of women [ 16 ].
On the other hand, the unequal distribution of power, resources and responsibilities between men and women has been institutionalized traditionally and has even taken root in women’s own thoughts and has become a rule. In many societies, women are in charge of nutrition, immunization, cleaning, hygiene, management, organizing ceremonies and celebrations without receiving wages, and women must perform tasks such as cleaning, raising children, cooking, and taking care of their husband [ 17 ]. Having children is considered one of the main goals of marriage [ 18 ]. Therefore, social and cultural norms and beliefs impose significant pressure on women by imposing gender expectations on them [ 14 ].
Considering that MS is more common in women of reproductive age, it may have a significant and long-term effect on women and families who are affected by this condition [ 19 ]. One view about pregnancy and the birth of a baby from a mother with MS is that pregnancy is potentially dangerous for the mother and her baby [ 19 ].
Another common concern in MS patients is sexual dysfunction. Sexual dysfunction is a very common and devastating problem in people with MS [ 20 ]. Young women with MS face challenges in finding a partner, raising a family, and managing their sex lives [ 21 ]. Studies show that patients are very discouraged by the behavior of people around them and their seemingly sympathetic advice [ 22 ]. A major issue in MS employment research is the strong effect of disease status on occupational participation [ 23 ]. Studies show that MS affects the occupational status of patients in various ways. Discrimination in the workplace may result in wrongful termination or failure to provide reasonable accommodations [ 24 , 25 , 26 ].
A qualitative study conducted explained the psychosocial factors of the burden of illness and demonstrated that patients with multiple sclerosis experience stress, agitation, and stigmatization [ 27 ]. However, in addition to the psychosocial challenges, women with MS also experience other challenges. Some of these challenges can be related to beliefs, perceptions, and cultural barriers [ 28 ]. In the long term, insensitivity to cultural aspects can have adverse effects on health and thus perpetuates health inequalities [ 29 ].
Many studies have addressed one or two cultural factors affecting the occurrence or exacerbation of MS; however, due to the diversity and extent of cultural factors, none of them provided integrated classification of these factors and the true contribution of cultural factors on the health outcomes of MS patients is not understood. Since studies have not specifically focused on cultural factors affecting MS, in this study, an attempt was made to understand and classify cultural factors that are effective in exacerbating MS. Cultural beliefs are crucial for providing adequate care and support, and efforts to break cultural barriers also enable better care for people with MS. By addressing this research gap, we can help to develop effective cultural interventions. Which ultimately leads to improving the attitude and reducing the health disparity of MS patients.
This study employed a qualitative approach with conventional content analysis to examine women patients with multiple sclerosis (MS) in Mashhad, Iran, a major city located in the eastern part of the country, during the year 2022.
In this research, the purposeful sampling method was used and the sampling continued until data saturation was reached.
Considering the maximum diversity in social situations in the city level (from different geographical, urban, and rural areas and different ages), the participants were selected from among 4600 patients admitted to the comprehensive MS center and the MS association. Age, duration of illness, level of education, marital status, and occupation were among the important underlying factors considered in this study.
With official permission, the researcher went to the Comprehensive MS Center and the MS association. She explained the purpose and importance of the research to the officials, and the necessary coordination was conducted with the officials of each department. Then, while communicating with the patient, the researcher explained the objectives, the importance of the research and the conditions of the research to the patients. Participants were allowed to bring their family or caregiver with them during the interview. However, all participants preferred to be interviewed alone. Finally, the patients who wanted to participate in the interview were selected and were interviewed after the necessary coordination.
Iranian patients with MS (according to the 2017 McDonald criteria) [ 30 ] and residents of Mashhad, can participate in this study after voluntarily completing and signing the consent form, if at least one year has passed since their MS was diagnosed by a physician. The exclusion criterion was the unwillingness of the participants to continue their cooperation at each stage of the research.
Before the interviews, the objectives and importance of the research were explained to the participants. The patients were assured that all information and interviews are only for research purposes and confidentiality and anonymization of information is respected in all stages. The participants’ voices were recorded with their permission. All the stages of this study were conducted following the Helsinki Declaration.
Face-to-face semi-structured interviews were conducted with MS patients to collect data. After twelve patients were interviewed, the data became saturated because no new concepts were obtained from the interviews, and the codes and concepts were repeated. It should be noted that three more interviews were conducted to ensure data saturation. Interviews were conducted by the first author (FP: who is a PhD student in health education and health promotion). The interviewer had experience and interest in conducting interviews on factors related to MS. No of the participants withdrew from the study. Two test interviews were conducted to assess the validity of the tool.
Quantitative and qualitative articles on the cultural factors affecting MS worldwide were reviewed to guide the related questions. The questions were then formulated and revised according to the experiences of the research team. The guide questions are provided in Supplementary File 1 .
For example, in this study, questions were asked such as has this disease affected your relationships with others? If yes, how? Can MS affect others relationship with your? Explain it. What factors cause you worry? Explain it.
At the end of any interview, the researcher asked the participants to talk about any topic they wanted, which the researcher did not mention. The interviews were conducted in the MS Comprehensive Center that was suitable in terms of ventilation, light, and sound.
The interviews were conducted between July and September 2022. Depending on the participant’s tolerance level and environmental factors, the duration of each interview varied from 30 to 63 min. In order for personal thoughts to not affect the process of data collection and analysis, the researcher wrote down her thoughts on paper to avoid emphasizing them.
During the study, the researcher carefully observed the participants’ behaviors in terms of feelings, emotions, and reactions. The researcher then added notes collected during the observations to the interview margins. The researcher provided her contact information to the participants so that wherever the participants felt the need to provide more detailed information to the researcher, they could contact the researcher.
A qualitative data analysis was performed using the five-step approach proposed by Graneheim and Lundman. In the first stage, immediately after completing the interviews, the recorded interviews were written on paper to create the primary data. In the second step, the texts were read several times to obtain a general understanding of their content. In the third step, the textual content is divided to determine semantic units and basic codes. In the fourth step, to obtain more comprehensive categories, the primary codes were classified based on their similarities and differences. In the fifth stage, the main subject of each category was determined [ 31 ]. First, the voices of participants were voluntarily recorded using a mobile phone recorder. Data backup was ensured by using two voice recorders. After each interview, the recorded interviews were transcribed on paper and were read several times. In the next step, handwritten transcripts were typed in Word 2016 as the primary research data. Typed interviews were analyzed using MAXQDA version 10 software. In the next step, the important sentences and phrases were first determined, and then the words and sentences (semantic units) were coded by the researcher, and open codes were formed. After the initial codes were extracted, those that were semantically and conceptually similar or related were classified into a category and formed a subcategory of a single topic with a higher level of abstraction. After the formation of more comprehensive categories, the analysis process continued to create the main and subcategories. To check the created codes, an independent researcher also checked the codes, and if there was an unresolved difference between the first and second researchers, the third researcher entered to resolve the difference (Fig. 1 ).
Validity, verifiability, transferability, and reliability are the four standards of Lincoln and Guba that were considered to strengthen the data [ 32 , 33 ]. To validate the data, interviews were conducted with various patients. The extracted codes and texts were shared with several interviewees. To review the transcribed interviews, several meetings were held with the team leader.
To ensure the correctness of data, some of the codes and free subsets were checked by experts. In addition, part of the interpretation of the participants was checked by the participants themselves and corrections were made wherever needed.
To assure the transferability of the data, a purposeful sampling method was used, and sampling was performed with maximum diversity and continued until data saturation. The researchers increased the transferability of the data by providing a detailed and step-by-step description of how to conduct the research process, and also described the characteristics of the studied population in order for other researchers to follow the research process. To check the reliability, the research team revised the process in two steps. In the first stage, partial reliability control was carried out and that the researchers checked the categories and coding instructions after working with 10–50% of the data. In the second step, the general reliability was examined by listing the final category at the end of the task (Fig. 1 ).
Flowchart of methodological steps
Tis study was performed through semi-structured interviews with 15 patients with MS. Participants ranged in age from 27 to 52 years with a mean age of 37.13 years old and standard deviation (± 7.49). Participant’s duration of the disease ranged in from 3 to 22 years with a mean of 9.99 and standard deviation (± 6.46). (Table 1 ).
Analysis of the 15 interviews resulted in 138 extracted codes, and after exclusion of the duplicate codes, a total of 22 main codes remained. These codes were classified into five sub-categories (Obligatory communication with the spouse’s family, definition of women’s role in society, people’s behavior, societal beliefs and patient isolation) and one main categories (cultural tensions). More complete results can be seen in Table 2 .
In the following, we will describe each of the categories.
First subcategory: obligatory communication with the spouse’s family.
The participants reported that obligatory communication with the spouse’s family such as unwanted participation in parties, tolerating snide comments and remarks for the sake of their spouse, keeping the spouse’s family happy, recurring arguments, jealousy, turning their husband against them, and constant judgments were associated with worsening symptoms.
Participant No. 7 (Duration of illness 3 years): “… my husband doesn’t know about my illness, I don’t want him to know about my illness, because I’m afraid that my husband will tell his family, I haven’t visited my husband’s family for a long time, because communicating with them bothers me. Fortunately, now that I don’t see them anymore I feel much better. That’s why I’m calm. That’s the only reason. When I look back, I ask myself why did I make such a mistake! I ask myself, when they create so many problems for me and my children, why did I go and see them in the first place? Why did I keep telling myself that no, you should go visit them for the sake of your husband?”
Participant No. 8 (Duration of illness 13 years): “…there are many people who get on my nerves, like in the beginning my mother-in-law used to tease me a lot. It’s because of my mother-in-law’s behavior that I’m not well and that I’ve reached this point. Whenever I went to their house I used to come back sad and crying. Now it’s been forty days since the last time I went to their house. The last time, she said something to me again that made me very upset, my husband wanted us to go to his mother’s house but I said I won’t come to their house anymore, you go. There are some people whom you cannot break your relationship with. My mother-in-law disregards my illness, even though she knows that I am sick, she still speaks her mind.”
In this context, the participants consider societal beliefs about women’s roles such as taking care of their husband and children, housekeeping, being an income generator, keeping up appearances, meeting the expectations of the family, and having adequate sexual activities to be effective.
Participant No. 11 (Duration of illness 5 years): “… I have four children; I don’t have time to exercise at all. All day long, I am doing housework, taking care of children and cooking. I told my husband: One of the patients is participating in training classes, exercise classes, flower-making classes and goes out of the house sometimes and her condition has improved a lot, but he said to me: If I were that woman’s husband, I would definitely divorce her.” my husband believes that the wife’s job is doing housework.”
Participant No. 3 (Duration of illness 3 years): “… I tried very hard to always have good and perfect marital life, because my husband cares a lot about sexual matters. Sometimes I am not physically and mentally ready to have sex, but I know that I am obligated to have sex with my husband. Because if I say that I don’t want to have sex, my husband says: It’s because of your MS that you have a lower sex drive.”
In this context, the participants consider people’s behavior such as pitying the patient, changes in people’s views, and backbiting the patient’s family members to be effective.
Participant No. 4 (Duration of illness 9 years): “…we are like other people, we don’t like being pitied by others and people changing their behavior because of our illness, we are just like them, we are people, we have a life, only our condition has become a little more difficult, that’s all.”
Participant No. 7 (Duration of illness 12 years): “… I don’t have any expectations from the people around me, people are bad, if they find out that you have a problem, they take advantage of you.
In this context, the participants consider societal beliefs such as the belief that the patient should not get married nor get pregnant, the patient being a burden, and not having a place in society to be effective factors.
Participant No. 10 (Duration of illness 3 years): “…for now, my husband said: go and take the appropriate medicine and treatment, when your body reaches a stable state, then we will have a baby. It is not advisable to have a baby now. Of course, I’m also afraid, everyone also says it won’t be too late to have a baby, you should wait for a while.”
Participant No. 2 (Duration of illness 13 years): “… but one of the main reasons for choosing Cinnovex was that it was free, because I did not want my husband to pay for these issues. My husband does not say that he won’t pay, but I would be very upset if I became a burden on my husband.”
Participant No. 14 (Duration of illness 5 years): “… Everyone thinks of ideal things when getting married, and everyone wants to choose a beautiful, healthy, and rich girl for their son. I am very worried. If you say you are sick before marriage, they refuse to marry you.”
In this context, participants consider behaviors that lead to patient isolation such as reduced participation, ignoring the patient, and lack of trust in the patient, to be effective factors.
Participant No. 2 (Duration of illness 13 years): “…I didn’t tell the company that I was sick. If a private company knows that you are sick, they won’t hire you. Private companies are so conservative because of insurance issues, and most of the people there do not have a positive attitude and they aren’t fun people to work with, everyone is looking for their own interests and they might even take advantage of your illness, for example, the moment something bad happens, they will say that this lady has a problem and she is not fit for working in this company.”
Participant No. 7 (Duration of illness 12 years): “… I am his big sister, but without telling me anything, they went to propose for my brother, and they preferred not to include me. Then they said: We were afraid that something would be said during the proposal that would upset you. We didn’t tell you anything, for your own sake. But it was pretty clear that they didn’t want me, who is sick and stutters because of my MS, to go to the proposal with them. They thought to themselves that if the girl’s family saw my condition, they wouldn’t let their daughter marry my brother.”
Participant No. 5 (Duration of illness 13 years): “… I was very stressed at work and my boss was very pushy about whether the work was done correctly or not. It was as if he did not trust my performance. Last time there was a fierce fight between us which made me leave the company, and again in the next company, there were still many challenges that were bothering me.”
This study aimed to explain the burden of cultural factors on Multiple sclerosis. Based on the results, one main category (cultural tensions) and five subcategories (obligatory communication with the spouse’s family, definition of women’s role in society, people’s behavior, societal beliefs and patient isolation) were constructed.
The results of this study showed that female MS patients are often forced to communicate with their spouse’s family in order to keep their spouse satisfied and prevent marital disputes. This obligatory communication may impose a lot of psychological pressure on them, which can lead to the exacerbation of the disease.
The behaviors of the spouse’s family, such as their interferences, jealousy, selfishness, gossips, vilification, insults, disrespect and their objections to the lack of sociability of the husband and wife cause consequences such as increasing worries, increasing tension between spouses, and the emergence and onset of depression symptoms [ 34 , 35 ]. The results of Datta’s study showed that conflict with the husband’s family and especially the mother-in-law is a fundamental issue in the topic of marital conflicts [ 36 ]. A dissatisfying relationship with one’s mother-in-law is an important risk factor for married women, which endangers their health [ 37 ].
The results of this study showed that female MS patients, due to the societal expectations of women’s role, are often forcing themselves to act a certain way in order to keep their husbands happy and avoid marital disputes. This forced relationship may impose a lot of psychological pressure on them, which leads to the exacerbation of their disease.
The main views of men and women about how to do housework have not changed much, and housework and taking care of children are still considered the main duties of women [ 38 ].
The role of women has changed due to economic conditions and social demands, women have to endure tremendous pressure to get a job similar to their men counterparts, while having to maintain an active role in their personal life [ 39 ].
Work-life balance is a key issue in all types of jobs due to dual-career families becoming more common and stressful jobs with long hours becoming the norm. Work life integrated with personal life creates stress [ 40 ].
People with MS, considering the types of sexual dysfunction and its indirect effects on mental health, quality of life and intimate relationships, may see sexual dysfunction as the most negative feature of this disease [ 41 ].
The results of this study showed that female patients with MS often experience changes in the views and behaviors of those around them, and these behavioral changes are disturbing and lead to the exacerbation of their disease.
A study showed that being pitied by others is an uncomfortable situation that is characterized by a lack of understanding of the situation [ 42 ]. Another study showed that most patients notice a change in other people’s opinions of them after the diagnosis [ 43 ].
The results of a study showed that the patients’ families believed that because of the label of the disease, in addition to the patient themselves, the families are also treated differently. They felt that they were judged negatively and were simply ignored [ 44 ].
The results of a study showed that the support of the surrounding people should be such that it does not cause the patients to be dependent on them or create a feeling of being pitied in the patients, so that they can find the identity and purpose of their lives in post-illness conditions [ 45 ].
According to our study, the exposure of female MS patients to societal beliefs increases negative feelings, such as avoiding marriage and feeling like a burden, and these negative feelings are the basis for the exacerbation of the disease.
Women would avoid having children due to the false belief that it would worsen the overall course of the disease [ 46 ].
MS is diagnosed in adulthood and is more common in women. Therefore, many women with this disease are discouraged from starting a family when their disease is diagnosed [ 47 ].
Although pregnancy has been shown to have no effect on MS and MS to have no effect on pregnancy, some women may still be discouraged by some family members and health professionals [ 19 ].
Some patients expressed their discomfort with feeling like a burden and that their family is wasting a lot of time and money on them [ 48 ].
The importance of raising the awareness of family and community members about their possible negative influence on the MS patients and encouraging them to review their behaviors to prevent putting more pressure on the patients, should be emphasized [ 49 ].
Not considering a specific position for these people in society creates difficult and unfortunate conditions for them, especially those who had strong personalities and were influential members of society before contracting the disease [ 50 ].
Patients with physical disabilities believe that their functional limitations cause problems for their caregivers and significant others. Feeling like a burden may lead to distress and complicate the relationship with the caregiver [ 51 , 52 ].
Considering that many women with MS are vulnerable to societal beliefs, it is necessary to formulate policies to change these beliefs so that society can take a step towards positive changes, and to reduce the frequency of these behaviors.
The results of this study showed that female MS patients are ignored by others during the disease, and the trust of others in their abilities decreases. This Distrust may impose a lot of psychological pressure on them, which leads to the exacerbation of their disease.
The results of studies show that many MS patients face a challenging work life. A higher proportion of people with MS report unemployment, part-time employment or reduced working hours, and lower income compared to the general population [ 23 , 53 ].
MS is associated with work difficulties, reduced working hours or their involvement and participation in their workplace, being transferred to jobs or other departments that is below their skill or knowledge level due to their employers’ impression that they are unable to handle the stress or the pressure of such works, and termination of voluntary and involuntary work or unemployment [ 54 ]. Greiton et al. found that the gender of women with MS was associated with their rate of unemployment [ 55 ].
Negative encounters such as discrimination and uncertainty from colleagues, managers or supervisors, and work organizations contribute to job transfer and termination, while positive support is associated with organizational embeddedness and job continuity [ 56 , 57 ].
Women with disabilities have also historically faced double discrimination due to their physical disability and gender, and have been ignored in many parts of society [ 58 ]. Simmons et al.‘s study showed that many MS sufferers have difficulty keeping jobs, even in good economic times [ 59 ].
Most of the participants were dissatisfied with the normalization of the disease for the doctors, followed by their superficial response to the patient and the lack of sufficient attention to the patient, and this issue had reduced their motivation to pursue treatment and follow medical recommendations [ 60 , 61 ].
The results of this study are limited to explaining the burden of cultural factors on disease worsening in women with MS in the Iranian culture. Therefore, to benefit from the findings of this study, it is necessary to conduct similar investigations in other fields and cultures. Although the researcher tried his best to be neutral during the interviews. However, this important principle may not have been inadvertently observed. Finally, more research is needed to provide complete insight into the cultural factors associated with MS.
The results obtained in this study show that female MS patients face concerns. Overcoming these challenges require a change in the attitude of people in the society towards women with MS, which is important in the context of formulating practical policies to create a suitable culture. Adopted policies should aim to internalize the culture of changing society’s views of female MS patients.
Therefore, the authors argue that there is a need for cultural policies, followed by the systems implementing these policies to consider the challenges mentioned in this study as a priority for MS patients.
The data sets used and/or analyzed during the current study was available from the corresponding author on reasonable request.
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This article is a part of the Ph.D. thesis in the field of Health Education and Health Promotion sponsored by Mashhad University of Medical Science and research project approved by Ethics Committee of Mashhad University of Medical Sciences with the code of ethics IR.MUMS. FHMPM.REC.1400.024 (Cod: 992067). The authors of the study express their sincere gratitude to all authorities of the Student Research Committee of Mashhad University of Medical Sciences and MS comprehensive center.
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Fahimeh Pourhaji, Nooshin Peyman & Hadi Tehrani
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Authors FP, HT, NP, MM and JJ designed the study. FP, HT and NP participated in the conception of the study. FP and HT managed and conducted the statistical analyses and interpreted the data. FP, HT, and NP wrote the first draft and FP, MM, HT and JJ revised it to make the final manuscript. All authors have read and approved the final manuscript.
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The midwife-led model of care is woman-centered and based on the premise that pregnancy and childbirth are normal life events, and the midwife plays a fundamental role in coordinating care for women and linking with other health care professionals as required. Worldwide, this model of care has made a great contribution to the reduction of maternal and child mortality. For example, the global under-5 mortality rate fell from 42 deaths per 1,000 live births in 2015 to 39 in 2018. The neonatal mortality rate fell from 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018. Even if this model of care has a pivotal role in the reduction of maternal and newborn mortality, in recent years it has faced many challenges.
To explore facilitators and barriers to a midwife-led model of care at a public health institution in Dire Dawa, Eastern Ethiopia, in 2021.
: A qualitative approach was conducted at Dire Dawa public health institution from March 1–April 30, 2022. Data was collected using a semi-structured, in-depth interview tool guide, focused group discussions, and key informant interviews. A convenience sampling method was implemented to select study participants, and the data were analyzed thematically using computer-assisted qualitative data analysis software Atlas.ti7. The thematic analysis with an inductive approach goes through six steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up.
Two major themes were driven from facilitators of the midwife-led model of care (professional pride and good team spirit), and seven major themes were driven from barriers to the midwife-led model of care (lack of professional development, shortage of resources, unfair risk or hazard payment, limited organizational power of midwives, feeling of demoralization absence of recognition from superiors, lack of work-related security).
The midwifery-led model of care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally. A multidisciplinary and collaborative effort is needed to solve those challenges.
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A midwife-led model of care is defined as care where “the midwife is the lead professional in the planning, organization, and delivery of care given to a woman from the initial booking to the postnatal period“ [ 1 ]. Within these models, midwives are, however, in partnership with the woman, the lead professional with responsibility for the assessment of her needs, planning her care, referring her to other professionals as appropriate, and ensuring the provision of maternity services. Most industrialized countries with the lowest mortality and morbidity rates of mothers and infants are those in which midwifery is a valued and integral pillar of the maternity care system [ 2 , 3 , 4 , 5 ].
Over the past 20 years, midwife-led model of care (MLC) has significantly lowered mother and infant mortality across the globe. In 2018, there were 39 deaths for every 1,000 live births worldwide, down from 42 in 2015. From 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018, the neonatal mortality rate (NMR) decreased. The midwifery-led care approach is regarded as the gold standard of care for expectant women in many industrialized nations, including Canada, Australia, the United Kingdom, Sweden, the Netherlands, Norway, and Denmark. Evidence from those nations demonstrates that women and babies who get midwife-led care, as opposed to alternative types of care, experience favorable maternal outcomes, fewer interventions, and lower rates of fetal loss or neonatal death [ 6 , 7 , 8 ].
In Pakistan, the MLC was accompanied by many challenges. Some of the challenges were political threats, a lack of diversity (midwives had no opportunities for collaborating with other midwives outside their institutions), long duty hours and low remuneration, a lack of a career ladder, and a lack of socialization (the health centers are isolated from other parts of the country due to relative geographical inaccessibility, transportation issues, and a lack of infrastructure). Currently, in Pakistan, 276 women die for every 100,000 live births, and the infant mortality rate is 74/1000. But the majority of these deaths are preventable through the midwife-led care model [ 7 ].
The MLC in African countries has faced many challenges. Shortages of resources, work overload, low inter-professional collaboration between health facilities, lack of personal development, lack of a well-functioning referral system, societal challenges, family life troubles, low professional autonomy, and unmanageable workloads are the main challenges [ 8 ].
Due to the aforementioned challenges, Sub Saharan Africa (SSA) is currently experiencing the highest rate of infant mortality (1 in 13) and is responsible for 86% of all maternal fatalities worldwide. As a result, it is imperative to look at the MLC issues in low-income countries, which continue to be responsible for 99% of all maternal and newborn deaths worldwide [ 8 , 9 ].
Ethiopia’s has a Maternal mortality rate (MMR) and NMR of 412 per 100,000 live births and 33 per 1000 live births, respectively, remain high, making Ethiopia one of the largest contributors to the global burden of maternal and newborn deaths, placed 4th and 6th, although MLC could prevent a total of 83% of all neonatal and maternal fatalities in an environment that supports it. The MMR & infant mortality rate (IMR) in the research area were indistinguishable from that, at 150 per 100,000 live births and 67 fatalities per 1,000 live births, respectively [ 10 , 11 , 12 , 13 ].
Since the Federal Ministry of Health is currently viewing midwifery-led care as an essential tool in reducing the maternal mortality ratio and ending preventable deaths of newborns, exploring the facilitators and barriers of MLC may have a great contribution to make in reducing maternal and newborn mortality [ 14 ]. Since there has been no study done in Ethiopia or the study area regarding the facilitators and barriers of MLC, the aim of this research was to explore the facilitators and barriers of MLC in Dire Dawa City public health institutions.
In so doing, the research attempted to address the following research questions:
What were the facilitators for a midwife-led model of care at the Dire Dawa city public health institution?
What were the barriers to a midwife-led model of care at the Dire Dawa city public health institution?
Institutional based qualitative study was conducted from March 01-April 30, 2022 in Dire Dawa city. Dire Dawa city is one of the federal city administrations in Ethiopia which is located at the distance of 515killo meters away from Addis Ababa (the capital city) to the east. The city administration has 9 urban and 38 rural kebeles (kebeles are the smallest administrative unit in Ethiopia). There are 2 government hospitals, 5 private hospitals, 15 health centers, and 33 health posts. The current metro area population of Dire Dawa city is 426,129.Of which 49.8% of them are males and 50.2% females. The total number of women in reproductive age group (15–49 years) is 52,673 which account 15.4% of the total population. It has hot temperature with a mean of 25 degree centigrade [ 15 ].
The source population for this study included all midwives who worked at Dire Dawa City public health facilities as well as key informants from appropriate organizations (the focal person for the Ethiopian Midwives Association and maternal and child health (MCH) team leaders). The study encompassed basically 41 healthcare professionals who worked in Dire Dawa public health institutions in total, and the final sample size was decided based on the saturation of the data or information.
From the total 15 Health centers and 2 Governmental Hospitals found in Dire Dawa city administration, 8 Health centers and 2 Governmental Hospitals were selected by non-probability purposive sampling method. In addition to that a non-probability convenience sampling method was used to select midwives who were working in Dire Dawa city public health institutions and key informants from the relevant organization such as Ethiopian midwives association focal person and MCH team leaders. Midwives who were working for at least six months in the institution were taken as inclusion criteria while those who were working as a free service were excluded from the study.
Focus groups, in-depth interviews, and key informant interviews were used in collecting data. A voice recorder, a keynote-keeping, and a semi-structured interview tool were all used to conduct the interviews. Voluntary informed written consent was obtained from the study participant’s before they participated in the study. Then an in-depth interview and focus group discussion were held with midwives chosen from various healthcare organizations. The MCH department heads and the Dire Dawa branch of the Ethiopian Midwife Association served as the key informants. In-depth interview (IDI) and key informant interviews (KII) with participants took place only once and lasted for roughly 50–60 min. In the midwives’ duty room, the interview was held. Six to eight people participated in focus group discussions (FGD), which lasted 90 to 100 min. Two midwives with experience in gathering qualitative data gathered the information.
The qualitative design is prone for bias but open-ended questions were used to avoid acquiescence and 2 day proper training was given for the data collector regarding taking keynotes and recording using a tape recorder. For consistency and possible modification, a pretest was done in one FGD and In-depth interviews at non selected health institutions of Dire Dawa city administrations. A detailed explanation was given for the study participants about the objectives of the study prior to the actual data collections. All (FGDs, key informant interview and In-depth interviews) were taken in a silent place.
Atlas.ti7, a qualitative data analysis program, was used for analyzing the data thematically. An inductive approach to thematic analysis involves six steps: familiarization, coding, generation of themes, review of themes, defining and naming of themes, and writing up. By listening to the taped interview again, the data was transcribed. The participants’ well-spoken verbatim was used to extract and describe the inductive meanings of the statements. The data was then coded after that. Each code describes the concept or emotion made clear in that passage of text. Then we look at the codes we’ve made, search for commonalities, and begin to develop themes. To ensure the data’s accuracy and representation, the generated themes were reviewed. Themes were defined and named, and then the analysis of the data was written up.
Meeting standards of trustworthiness by addressing credibility, conformability, and transferability ensures the quality of qualitative research. Data triangulation, data collection from various sites and study participants, the use of multiple data collection techniques (IDI, KII, and FGD), multiple peer reviews of the proposal, and the involvement of more than two researchers in the coding, analysis, and interpretation decisions are all instances of the methods that were used in order to fulfill the criteria for credibility. To increase its transferability to various contexts, the study gave details of the context, sample size and sampling method, eligibility criteria, and interview processes. To ensure conformability, the research paths were maintained throughout the study in accordance with the work plan [ 16 , 17 ].
In this study, a total of 41 health care providers who are working in Dire Dawa public health facilities participated in the three FGDs, six KIIs, and fifteen IDIs. The years of experience of study participants range from one year to 12 years. The participants represented a wide age range (30–39 years), and the educational status of the respondents ranged from diploma to master’s degree. (Table 1 )
As shown in Table 2 , from the qualitative analysis of the data, two major themes were driven from facilitators of MLC, and seven major themes were driven from barriers to MLC. (Table 2 ).
Professional pride.
This study found that saving the lives of mothers and newborns was a strong facilitator. Specifically, it was motivational to have skills within the midwifery domain, such as managing the full continuum of care during pregnancy and labour, supporting women in having normal physiologic births, being able to handle complications, and building relationships with the women and the community, as mentioned below by one of the IDI participants.
“I am so proud since I am a midwife; nothing is more satisfying than seeing a pregnant mother give birth almost without complications. I always see their smile and happiness on their faces , especially in the postpartum period , and they warmly thank me and say , “Here is your child; he or she is yours.” They bless me a lot. Even sometimes , when they sew me in the transport area , cafeteria , or other area , they thank me warmly , and some of them also want to invite me to something else. The sum total of those things motivates me to be in this profession or to provide midwifery care.“ IDI participants.
This finding is also supported by other participants in FGD.
“We have learned and promised to work as midwives. We are proud of our profession , to help women and children’s health. The greatest motivation is that we are midwives , we love the profession , and we are contributing a great role in decreasing maternal and child mortality….” FGD discussant.
The research revealed that good midwifery teamwork and good social interaction within the staff have become facilitators of MLC. FGD participants share their experiences of working in a team.
“In our facility , all the midwives have good teamwork; we have good communication , and we share client information accurately and timely. In case a severe complication happens , we manage it as a team , and we try to cover the gap if some of our staff are absent. Further from that , we do have good social interactions in the case of weeding , funeral ceremonies , and other social activities. We do have good team spirit; we work as a team in the clinical area , and we also have good social relationships. “If some of our staff gets sick or if she or he has other social issues , the other free staff will cover her or his task.” FGD discussant.
Another participant from IDI also shared the same experience regarding their good teamwork and their social interactions.
“As a maternal and child health team , we do have a good team spirit , not only with midwives but also with other professions. We are not restricted by the ward that we assign. If there is a caseload in any unit , some midwives will volunteer to help the other team. Most of the time in the night , we admit more than 3 or 4 labouring mothers at the same time. Since in our health center only one midwife is assigned in the night , we always call nurses to help us. This is our routine experience.” IDI participants.
Lack of professional development.
This study revealed that insufficient opportunities for further education and updated training were the main barriers for MLC. Even the few trainings and update courses that were actually arranged were unavailable to them, either because they did not meet the criteria seated or because the people who work in administration were selected. Even though opportunities are not arranged for them to upgrade themselves through self-sponsored. One of the participants from IDI narrates her opinion about opportunities for further education as follows:
“Training and updates are not sufficient; currently we are almost working with almost old science. For example , the new obstetrics management protocol for 2021 has been released from the ministry of health , and many things have changed there. But we did not receive any training or even announcements. Even the few trainings and update courses that were truly organized and turned in to us are unavailable since the selection criteria are not fair. As a result , we miss those trainings either because we did not meet the selection criteria or because those who work in administration are prioritized.” IDI participant.
FGD discussants also support this idea. She mentioned that even though opportunities are not arranged for them to upgrade themselves through self-sponsorship,
“There is almost no educational opportunity in our institution. Every year , one or two midwives may get institutional sponsorship. Midwives that will be selected for this opportunity are those who have served for more than five to ten years. Imagine that to get this chance , every midwife is expected to serve five or more years. Not only this , even if staff want to learn or upgrade at governmental or private colleges through self-sponsored programmes , whether at night or in an extension programme , they are not cooperative. Let me share with you my personal experience. Before two years , I personally started my MSc degree at Dire Dawa University in a weekend programme , and I have repeatedly asked the management bodies to let me free on weekends and to compensate me at night or any time from Monday to Friday. Since they refuse to accept my concern , I withdraw from the programme.“ FGD discussant.
The finding indicates that a shortage of equipment, staff, and rooms or wards was a challenge for MLC. Midwives claimed they were working with few staff, insufficient essential supplies, and advanced materials. This lack of equipment endangers both the midwives and their patients. One of the participants from IDI narrates her opinion about the shortage of resources as follows:
“Of course there is a shortage of resources in our hospital , like gloves and personal protective devices. Even the few types of medical equipment available , like the autoclave , forceps , vacuum delivery couch , and BP apparatus , are outdated , and some of them are unfunctional. If you see the Bp apparatus we used in ANC , it is digital but full of false positives. When I worked in the ANC , I did not trust it and always brought the analogue one from other wards. This is the routine experience of every staff member.“ IDI participants.
Another participant from IDI also shared the same experience regarding the crowdedness of rooms or wards.
“In our health center , there are no adequate wards or rooms. For example , the delivery ward and postnatal ward are almost in one room. Postnatal mothers and neonates did not get enough rest and sleep because of the sound of laboring mothers. Not only is this , but even the antenatal care and midwifery duty rooms are also very narrow.“ IDI participants.
The study also revealed midwifery staff were pressured to work long hours because they were understaffed, which in turn affected the quality of midwifery care. The experience of a certain midwife is shared as follows:
“I did not think that the management bodies understood the risk and stress that we midwives face. They did not want to consider the risk of midwives even equal to that of other disciplines but lower than the others. For example , in our health centre , during the night , only one midwife is assigned for the next 12 hours , but if you see in the nurse department , two or more nurses are assigned at night in the emergency ward.” IDI participants.
The discussion affirms the fact that being understaffed and not having an adequate allocation of midwife professionals on night shifts are affecting labouring mothers’ ability to get sufficient health midwifery care. The above narration is also supported by the FGD discussant.
“In our case , only one midwife is assigned to the labour ward during the night shift. I think this is the main challenge for midwives that needs attention. Let me share with you my experience that happened months before. While I was on night shift , two labouring mothers were fully dilated within three or four minutes. It was very difficult for me , to manage two labouring mothers at the same time. Immediately , I call one of my nurse friends from the emergency department to help me. If my friend was so busy , what could happen to the labouring mother and also to me? This is not only my experience but also the routine experience of other midwives.” FGD discussant.
It is reported that the compensation amount paid for risk is lower than in other health professions. The health risks are not any less, but the remuneration system failed to capture the need to fairly compensate midwifery professionals. The narration from the FGD discussant regarding unfair payment is mentioned below.
“Only 470 ETB is paid for midwives as risk payments , which is incomparable with the risks that midwives are facing. But contrary to that , the risk payments for nurses (in emergencies) are about 1200 Ethiopian birr (ETB) , and Anesthesia is 1000 ETB. I did not want to compare my profession with other disciplines , but with the lowest cost , how the risk of midwifery cannot be equal to that of nursing and other professions. I did not know whose professionals made such types of unfair decisions and with what scientific background or base this calculation was done . ” FGD discussant.
The above finding is also supported by an IDI participant.
“………………………….Even though the midwifery profession is full of risks , with the current Ethiopian health care system , midwives are being paid the lowest risk payments compared to other disciplines…………….” IDI participants.
Midwives’ interviews reported that limited senior midwifery positions in the health system have become the challenge of midwifery care. This constrains the decision-making power and capability of midwives. This was compounded by limited opportunities for midwifery personnel to address their concerns to the responsible bodies, as stated by one of the key informants.
“Our staff has many concerns , especially professional-related concerns , which can contribute to the quality of midwifery care. Personally , as department head , I have tried to address those concerns in different management meetings at different times. But since the leadership positions are dominated by other disciplines , many of our staff concerns have not been solved yet. But let me tell you my personal prediction… If those concerns are not solved early and if this trend continues , the quality of midwifery care will be in danger.“ Participant from Key Informant.
The above finding is also supported by another IDI participant.
“In our hospital , at every hierarchal and structural level , midwives are not well represented. That is why all of our challenges or concerns have not been solved yet. For example , as a structure in the Dire Dawa Health Office (DDHO) , there is a team of management related to maternal and child health. But unfortunately , those professionals working there are not midwives. I was one of three midwives chosen to meet with Dr. X (former DDHO leader) to discuss this issue. At the time , we were reaching an agreement that two or three midwives would be represented on that team. But since a few months later the leader resigned , the issue has not gotten a solution yet.“ IDI participant.
One of the main concerns reported by the participants during the interviews was a feeling of demoralization induced by both their clients and their supervisors about barriers to midwifery care. They reported having been verbally abused by their patients, something that made them feel that their hard work was being undermined, as stated by an FGD participant.
“I don’t think there is any midwife who would be happy for anybody to lose their baby , or that there is any midwife who would want a woman to die. These things are accidents , but the patient and leaders will always blame the midwife.” FDG discussant.
A narration from an IDI participant also mentioned the following:
“……….If something happens , like a conflict with the patients or clients , the management is on the patient side. Not only that , the way in which they communicate with us is in an aggressive or disrespectful manner . ” IDI participant.
This study revealed that midwives experience a loss of motivation at work due to limited support from their superiors. Their effort is used only for reporting purposes. A midwife from FGD shared her experience as follows.
“In our scenario , till the nearest time , the maternal and child health services are provided in a good way. But this was not easy; it is the cumulative effort of midwives. But unfortunately , only those in managerial positions are recognized. Nothing was done for us despite our efforts. To me , our efforts are used only for reporting purposes.” FGD discussant.
This finding was also supported by IDI participants.
“Even though we have good achievements in the MCH services , there is no motivation mechanism done to motivate midwives.” But if something or a minor mistake happens , they are on the front lines to intimidate us or write a warning letter. Generally , their concern is a report or a number issue. We are tired of such types of scenarios.” IDI participant.
One of the main concerns reported by the participants during the interviews was the work related security, which has become a challenge for MLC. The midwives’ work environment was surrounded by insecurity, especially during night shifts, when midwives were facing verbal and even physical attack, as mentioned by participants.
“In the labour ward , especially at night , we face many security-related issues. The families of labouring mothers , especially those who are young , are very aggressive. Sometimes they even want to enter the delivery room. They did not hear what we told them to do , but if they hear any labour sounds from their family , they disturb the whole ward. This leads to verbal abuse , and sometimes we face physical abuse. There may be one or two security personnel at the main gate , but since the delivery ward is far from the main gate , they do not know what is happening in the delivery ward. When things become beyond our scope , we call security guards. Immediately after the security guards go back , similar things will continue. What makes it difficult to manage such situations is that only one midwife is assigned at night , and labouring mothers will not get quality midwifery care.” IDI participant.
FGD discussants also shared their experience that their working environment is full of insecurity.
“In case any complications occur , especially at night , it is very difficult to tell the labouring mother’s family or husband unless we call security personnel. It is not only swearing that we face but also that they intimidate us.” FDG discussant.
The aim of this study was to explore facilitators’ and barriers to a midwifery-led model of care at Dire Dawa public health facilities. In this study, professional pride was the main facilitator of the midwifery-led model of care. Another qualitative study that examined the midwifery care challenges and factors that motivate them to remain in their workplace lends confirmation to this conclusion. It was found that a strong feeling of love for their work was the main facilitator’s midwifery-led model of care [ 9 ]. Having a good team spirit was also another facilitator’s midwifery-led model of care in our study. Another study’s findings confirmed this one, which emphasizes that building relationships with the midwives, women, and community was the driving force behind providing midwifery care [ 7 , 18 ].
The midwives in this study expressed a need for additional professional training, updates, and competence as part of their continuing professional development. Similar findings have been reported in the worldwide literature that midwives were struggling for survival due to a lack of limited in-service training opportunities to improve their knowledge and skills [ 19 ]. This phenomenon does not seem to differ between settings in high-, middle-, and low-income countries [ 7 , 9 , 18 ], in which midwives experienced difficult work situations due to a lack of professional development to autonomously manage work tasks, which made them feel frustrated, guilty, and inadequate. As such, this can contribute to distress and burnout, which in turn prevent midwives from being able to provide quality care and can eventually cause them to leave the profession [ 19 ].
Shortages of resources (shortage of staff, lack of physical space, and equipment) were the other reported barriers to midwifery care explored in this study. They reported that they are working in an environment with a shortage of resources, which leads to poor patient outcomes. This finding is supported by many other studies conducted around the globe [ 20 , 21 , 22 , 23 ]. Another qualitative finding, which likewise supports the aforementioned finding, which emphasizes that a shortage of resources was reported as a barrier to providing adequate midwifery care [ 19 ]. Delivery attended by skilled personnel with appropriate supplies and equipment has been found to be strongly associated with a reduction in child and maternal mortality [ 24 ].
The feeling of demoralization and lack of motivation from their superiors were other barriers to midwifery care explored in this study. This finding is concurrent with other studies conducted around the globe [ 19 , 25 , 26 , 28 ]. The above finding is also is in accord with another qualitative narration, which emphasizes that feelings of demoralization and a lack of motivation were the main challenges of midwifery care [ 22 ]. Positive support from supervisors has been demonstrated to be important for the quality of services that health workers are able to deliver. In the World Health Organization’s report on improving performance in healthcare, the WHO stresses that supportive supervision can contribute to the improved performance of health workers [ 27 ].
Unfair risk payment was the other challenge identified by the current study. Even though there is no difference in the risk they face among health professionals, the risk payment for midwives is very low compared to others. This finding was in conformity with another qualitative narration, which emphasizes that the lack of an equitable remuneration system was experienced by the DRC midwives, and it has also been confirmed to be highly problematic in other studies in low- and middle-income settings [ 7 , 8 , 22 , 28 ], leading to serious challenges. In settings where salaries are extremely low or unpredictable, proper remuneration is seen as crucial to worker motivation and the quality of midwifery care [ 29 , 30 ].
The limited organizational power of midwives was another identified challenge of MLC. This finding was in step with other studies that emphasize that limited senior midwifery positions in the health system constrain the decision-making power and capability of midwives. This was compounded by limited opportunities for midwifery personnel to address their concerns to the responsible bodies. Hence, midwives need to take control of their own situations. When midwives are included in customizing their work environments, it has proven to result in improved quality of care for women and newborns around the globe [ 8 , 15 ].
Lack of work-related security was another barrier to MLC explored in this study, in which the midwives’ work environment was surrounded by insecurity, especially during night shifts, when midwives are facing verbal and even physical attack, as mentioned by participants. This finding is supported by many other studies conducted around the globe [ 22 , 23 , 25 , 31 ]. The above finding is also in agreement with another qualitative narration, which emphasizes that the midwives’ work environment was surrounded by insecurity, especially during night shifts due to a lack of available security personnel; they often felt frightened on their way to and from work [ 7 ]. In order for midwives to provide quality care, it is crucial to create supportive work environments by ensuring sufficient pre-conditions, primarily security issues [ 31 ].
The study findings contribute to a better understanding of the facilitators’ and barriers of a midwifery-led model of care in the case of Dire Dawa public health facilities. Professional pride and having good team spirit were the main facilitators of midwifery-led model care. Contrary to that, insufficient professional development, shortage of resources, feeling of demoralization, lack of motivation, limited organizational power of midwives, unfair risk payment, and lack of work-related security were the main barriers to a midwifery-led model of care in the case of Dire Dawa public health facilities. Generally, midwifery care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally.
The findings of the study have implications for midwifery care practices in Eastern Ethiopia. Addressing these areas could potentially contribute to the reduction of IMR and MMR.
The first strength of the study is that the participants represented different healthcare facilities, both urban and rural, thereby offering deeper and more varied experiences and reflections. A second strength is using a midwife as a moderator. She or he understood the midwives’ situation, thereby making the participants feel more comfortable and willing to share their stories. However, focusing solely on the perspective of the midwives is a limitation.
To overcome the barriers of midwifery care, based on the result of this study and in accordance with the 2020 Triad Statement made by the International Council of Nurses, the International Confederation of Midwives, and the World Health Organization, it is suggested that policymakers, Ethiopian federal ministry of health, Dire dawa health office, and regulators in Dire Dawa city and settings with similar conditions coordinate actions in the following:
Should strengthen regular and continuous educational opportunities, trainings, and updates for midwives, prioritizing and enforcing policies to include adequate and reasonable remuneration and hazard payment for midwives. Support midwifery leadership at all levels of the health system to contribute to health policy development and decision-making.
Ensure decent working conditions and an enabling environment for midwives. This includes reasonable working hours, occupational safety, safe staffing levels, and merit-based opportunities for career progression. Special efforts must be made to ensure safe, respectful, and enabling workplaces for midwives operating on the night shift. Midwifery leaders should be involved in management bodies within an appropriate legal framework. Made regular mentorships on the functionality of different diagnostic instruments in respective health facilities.
Create an arena for dialogue and implement a more supportive leadership style at the respective health facilities. Should address professional-related concerns of midwives early. Ensure midwives’ representation at the management bodies. Ensure the selection criteria for educational opportunities and different trainings are fair and inclusive. Ensure the safety and security of midwives, especially those who work night shifts. Should assign adequate staff (midwives and security guards) to the night shifts.
Should influence different stakeholders to solve midwife’s concerns like hazards payment and educational opportunity.
All the datasets for this study are available from the corresponding author upon request.
Focused group discussion
In-depth interview
Infant mortality rate
Key informant interview
Maternal and child health
Midwives led model of care
Neonatal mortality rate
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We are very grateful to Dire Dawa University for the financial support for this study and to the College of Medicine and Health for its monitoring ship. All study participants for their willingness to respond to our questionnaire.
this work has been funded by Dire Dawa University for data collection purposes. The Dire Dawa University College of Medicine and Health Sciences was involved in the project through monitoring and evaluation of the work from the beginning to the result submission. However, this organization was not involved in the design, analysis, critical review of its intellectual content, or manuscript preparation, and its budget did not include publication.
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College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
Mickiale Hailu, Aminu Mohammed, Daniel Tadesse, Neil Abdurashid, Legesse Abera, Tadesse Weldeamaniel, Tekleberhan Hailemariam, Netsanet Melkamu, Tewodros Getnet, Yibekal Manaye, Tariku Derese, Muluken Yigezu, Natnael Dechasa & Anteneh Atle
College of Health Sciences, Wachemo University, Hossana, Ethiopia
Samrawit Ali & Yesuneh Dejene
College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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MH developed the study proposal, served as the primary lead for study implementation and data analysis/interpretation, and was a major contributor in writing and revising all drafts of the paper. AM, DT, NA, LA, and SA supported study implementation and data analysis, and contributed to writing the initial draft of the paper. YD, TW, MG, TH and, NM supported study recruitment and contributed to writing the final draft of the paper. TG, YM, TD, MY, ND and, AA conceptualized, acquired funding, and led protocol development for the study, co-led study implementation and data analysis/interpretation, and was a major contributor in writing and revising all drafts of the paper. All authors contributed to its content. All authors read and approved the final manuscript.
Correspondence to Mickiale Hailu .
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All methods were followed in accordance with relevant guidelines and regulations. The institutional review board of Dire Dawa University has also examined and evaluated it for its methodological approach and ethical concerns. Ethical clearance was obtained from Dire Dawa University Institutional Review Board and an official letter from research affairs directorate office of Dire Dawa University was submitted to Dire Dawa health office and it was distributed to selected health institutions. Voluntary informed written consent was obtained from the study participant’s right after the objectives of the study were explained to the study participants and confidentiality of the study participants was assured throughout the study period. Participants were informed that they have the right to terminate the discussion (interview) or they can’t answer any questions they didn’t want to answer.
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Hailu, M., Mohammed, A., Tadesse, D. et al. Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study. BMC Health Serv Res 24 , 998 (2024). https://doi.org/10.1186/s12913-024-11417-x
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The current study examines the (2 + 1)-dimensional fractional Chaffee–Infante (FCI) model, which is a nonlinear evolution equation that characterizes the processes of pattern generation, reaction-diffusion, and nonlinear wave propagation. The construction of analytical solutions involves the use of analytical methods, namely the Khater III and improved Kudryashov schemes. The He’s Variational Iteration method is employed as a numerical approach to validate the accuracy of the obtained solutions. The main objective of this study is to get novel analytical and numerical solutions for the FCI model, with the intention of gaining a deeper understanding of the system’s dynamics and its possible implications in the fields of fluid mechanics, plasma physics, and optical fiber communications. The study makes a valuable contribution to the area of nonlinear science via the use of innovative analytical and numerical methodologies in the FCI model. This research enhances our comprehension of pattern creation, reaction–diffusion phenomena, and the propagation of nonlinear waves in diverse physical scenarios.
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The authors extend their appreciation to Taif University, Saudi Arabia, for supporting this work through project number (TU-DSPP-2024-46).
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School of Medicine and Health, Harbin Institute of Technology, Harbin, 150001, Heilongjiang, China
Department of Mathematics, College of Science, Taif University, P.O. Box 11099, 21944, Taif, Saudi Arabia
Taher A. Nofal
Institute of Information Technology, Chelyabinsk State University, Chelyabinsk, 454001, Russia
Aleksander Vokhmintsev
Institute of Digital Economy, Ugra State University, Khanty-Mansiysk, 628012, Russia
Aleksander Vokhmintsev & Mostafa M. A. Khater
School of Medical Informatics and Engineering, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu Province, People’s Republic of China
Mostafa M. A. Khater
Department of Basic Science, The Higher Institute for Engineering & Technology, Al-Obour, Cairo, 10587, Egypt
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Xiao Zhang, and Mostafa M. A. Khater conceived and designed the experiments and performed them. Taher A. Nofal, Aleksander Vokhmintsev and Mostafa M. A. Khater analyzed and interpreted the data, contributed to the provision of reagents, materials, analysis tools, or data, and wrote the paper.
Correspondence to Mostafa M. A. Khater .
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Zhang, X., Nofal, T.A., Vokhmintsev, A. et al. Exploring Solitary Waves and Nonlinear Dynamics in the Fractional Chaffee–Infante Equation: A Study Beyond Conventional Diffusion Models. Qual. Theory Dyn. Syst. 23 (Suppl 1), 270 (2024). https://doi.org/10.1007/s12346-024-01121-w
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Received : 24 December 2023
Accepted : 07 August 2024
Published : 29 August 2024
DOI : https://doi.org/10.1007/s12346-024-01121-w
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