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  • 1. Bergström, Eva-Britt
    et al.
    Wallin, Lars
    Karolinska Institutet.
    Thomson, Gill
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Postpartum depression in mothers of infants cared for in a Neonatal Intensive Care Unit: Incidence and associated factors2012In: Journal of Neonatal Nursing, ISSN 1355-1841, Vol. 18, no 4, 143-51 p.Article in journal (Refereed)
    Abstract [en]

    This longitudinal cohort study investigated the incidence of postpartum depression (PPD) among mothers of infants cared for in two Neonatal Intensive Care Units (NICU) and factors related to PPD onset. 123 mothers were posted the Edinburgh Post-Natal Depression Scale (EPDS) and a questionnaire to record infant and maternal data at 1 month, and a repeat EPDS scale at 4 months post-discharge. PPD incidence was 15% at 1 month, 14% at 4 months, and varied by NICU (23% vs. 8%). Pre-pregnancy and/or antenatal depression was significantly associated with the incidence of PPD. Mothers who experienced PPD at 1 month had an almost eight fold risk of experiencing PPD at 4 months. Women who were not offered counselling during their infant’s stay on the NICU had a 60% increased risk for PPD onset. The findings highlight the need for routine pre-natal screening and targeted support for mothers with infants admitted to NICU.

  • 2.
    Dykes, Fiona
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom; Chinese University of Hong Kong, Hong Kong; University of Western Sydney, Australia .
    Flacking, RenéeDalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Chinese University of Hong Kong, Hong Kong; Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom.
    Ethnographic research in maternal and child health2015Collection (editor) (Other academic)
  • 3.
    Dykes, Fiona
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom; Chinese University of Hong Kong, Hong Kong; University of Western Sydney, Australia .
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Chinese University of Hong Kong, Hong Kong; Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom.
    Introducing the theory and practice of ethnography2015In: Ethnographic Research in Maternal and Child Health / [ed] Fiona Dykes and Renée Flacking, Taylor & Francis, 2015, 1-14 p.Chapter in book (Other academic)
  • 4.
    Dykes, Fiona
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. University of Central Lancashire, UK..
    Thomson, G
    Gardner, C
    Hall Moran, V
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Perceptions of European medical staff on the facilitators and barriers to physical closeness between parents and infants in neonatal units2016In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 105, no 9, 1039-1046 p.Article in journal (Refereed)
    Abstract [en]

    AIM: Studies have provided insights into factors that may facilitate or inhibit parent-infant closeness in neonatal units, but none have specifically focused on the perspectives of senior neonatal staff. The aim of this study was to explore perceptions and experiences of consultant neonatologists and senior nurses in five European countries with regard to these issues.

    METHODS: Six small group discussions and three one-to-one interviews were conducted with 16 consultant neonatologists and senior nurses representing nine neonatal units from Estonia, Finland, Norway, Spain and Sweden. The interviews explored facilitators and barriers to parent-infant closeness and implications for policy and practice and thematic analysis was undertaken.

    RESULTS: Participants highlighted how a humanising care agenda that enabled parent-infant closeness was an aspiration, but pointed out that neonatal units were at different stages in achieving this. The facilitators and barriers to physical closeness included socio-economic factors, cultural norms, the designs of neonatal units, resource issues, leadership, staff attitudes and practices and relationships between staff and parents.

    CONCLUSION: Various factors affected parent-infant closeness in neonatal units in European countries. There needs to be the political motivation, appropriate policy planning, legislation and resource allocation to increase measures that support closeness agendas in neonatal units. This article is protected by copyright. All rights reserved.

  • 5. Ericson, Jenny
    et al.
    Eriksson, Mats
    Hellstrom-Westas, Lena
    Hagberg, Lars
    Hoddinott, Pat
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden.
    The effectiveness of proactive telephone support provided to breastfeeding mothers of preterm infants: study protocol for a randomized controlled trial2013In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 13, 73Article in journal (Refereed)
    Abstract [en]

    Background: Although breast milk has numerous benefits for infants' development, with greater effects in those born preterm (at < 37 gestational weeks), mothers of preterm infants have shorter breastfeeding duration than mothers of term infants. One of the explanations proposed is the difficulties in the transition from a Neonatal Intensive Care Unit (NICU) to the home environment. A person-centred proactive telephone support intervention after discharge from NICU is expected to promote mothers' sense of trust in their own capacity and thereby facilitate breastfeeding.

    Methods/design: A multicentre randomized controlled trial has been designed to evaluate the effectiveness and cost-effectiveness of person-centred proactive telephone support on breastfeeding outcomes for mothers of preterm infants. Participating mothers will be randomized to either an intervention group or control group. In the intervention group person-centred proactive telephone support will be provided, in which the support team phones the mother daily for up to 14 days after hospital discharge. In the control group, mothers are offered a person-centred reactive support where mothers can phone the breastfeeding support team up to day 14 after hospital discharge. The intervention group will also be offered the same reactive telephone support as the control group. A stratified block randomization will be used; group allocation will be by high or low socioeconomic status and by NICU. Recruitment will be performed continuously until 1116 mothers (I: 558 C: 558) have been included. Primary outcome: proportion of mothers exclusively breastfeeding at eight weeks after discharge.

    Secondary outcomes: proportion of breastfeeding (exclusive, partial, none and method of feeding), mothers satisfaction with breastfeeding, attachment, stress and quality of life in mothers/partners at eight weeks after hospital discharge and at six months postnatal age. Data will be collected by researchers blind to group allocation for the primary outcome. A qualitative evaluation of experiences of receiving/providing the intervention will also be undertaken with mothers and staff.

    Discussion: This paper presents the rationale, study design and protocol for a RCT providing person-centred proactive telephone support to mothers of preterm infants. Furthermore, with a health economic evaluation, the cost-effectiveness of the intervention will be assessed. Trial registration: NCT01806480

  • 6. Ericson, Jenny
    et al.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Estimated breastfeeding to support breastfeeding in the neonatal intensive care unit2013In: Journal of Obstetric, Gynecologic and Neonatal Nursing, ISSN 0884-2175, E-ISSN 1552-6909, Vol. 42, no 1, 29-37 p.Article in journal (Refereed)
    Abstract [en]

    Objective. To evaluate the effects of estimated breastfeeding on infant outcomes in comparison to test weighing and to describe staff members experiences of estimated breastfeeding as a method for supporting the transition from tube feeding to breastfeeding.

    Design. A mixed method evaluation. Setting Neonatal Intensive Care Unit (NICU) in Sweden. Participants The study included 365 preterm (25th36th gestational weeks) infants and 45 nurses or nurse assistants. Methods A retrospective comparative medical record study was used to assess infant outcomes during a period of test weighing (196 infants) and again after the implementation of estimated breastfeeding (169 infants). A qualitative survey was conducted to explore the staff experiences of estimated breastfeeding.

    Results. No differences were found between groups regarding duration of tube feeding, length of hospital stay, gestational age, weight at discharge, and rate of any breastfeeding. Infants in the estimated breastfeeding group had a higher risk of not being exclusively breast milk fed than infants in the test-weighing group (OR = 2.76, CI [1.5, 5.1]). Staff perceived estimated breastfeeding as a more facilitative and less stressful method for mothers than test weighing. Some staff had difficulty following guidelines while simultaneously providing person-centered care.

    Conclusions. Estimated breastfeeding is a nonintrusive and feasible method for assessing and supporting the transition from tube feeding to breastfeeding among preterm infants in a NICU. However, the increased risk for not being exclusively breastfed is of concern. Additional research is needed to assess whether this method is appropriate and feasible in varying contexts and cultures. JOGNN, 42, 29-37; 2013. DOI: 10.1111/j.1552-6909.2012.01423.x

  • 7. Ericson, Jenny
    et al.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hellström-Westas, Lena
    Eriksson, Mats
    Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units: a register study over 10 years2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, e012900Article in journal (Refereed)
    Abstract [en]

    Objective: There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants.

    Design, setting and participants: This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004–2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups.

    Results: From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22–27 weeks) from 55% to 16%, in very preterm (GA 28–31 weeks) from 41% to 34% and in moderately preterm infants (GA 32–36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding and which became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants).

    Conclusions: In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.

  • 8. Finlayson, Kenneth
    et al.
    Dixon, Annie
    Smith, Chris
    Dykes, Fiona
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, UK.
    Mothers’ perceptions of family centred care in neonatal intensive care units2014In: Sexual & Reproductive HealthCare, ISSN 1877-5756, Vol. 5, no 3, 119-124 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To explore mothers' perceptions of family centred care (FCC) in neonatal intensive care units (NICUs) in England. 

    Design: The qualitative experiences of 12 mothers from three NICUs in the UK were elicited using individual interviews. A thematic network analysis was conducted on the transcribed interviews. 

    Main outcome measures: A central global theme supported by a number of organizing themes were developed reflecting the views of the mothers and their experiences of FCC. 

    Results: A global theme of "Finding My Place" was identified, supported by six organizing themes: Mothering in Limbo; Deference to the Experts; Anxious Surveillance; Muted Relations, Power Struggles and Consistently Inconsistent. Mothers experienced a state of liminality and were acutely sensitive to power struggles, awkward relationships and inconsistencies in care. To try to maintain their equilibrium and protect their baby they formed deferential relationships with health professionals and remained in a state of anxious surveillance. 

    Conclusions: This study illustrates that despite the rhetoric around the practice of FCC in NICUs, there was little in the mother's narratives to support this. It is of the utmost importance to minimize the consequences of the liminal experience, to improve staff-mother interactions and to facilitate mothers' opportunities to be primary caregivers. 

  • 9.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Amning och utbildning: hur hänger det ihop?2010In: Barnläkaren, ISSN 1651-0534, no 4, 19-20 p.Article in journal (Refereed)
  • 10.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Feeding preterm infants in Sweden: challenges to implementing the Global Strategy in a pro-breastfeeding culture2009In: Infant and Young Child Feeding : Challenges to implementing a Global Strategy / [ed] Dykes, Fiona; Hall Moran, Victoria, Oxford: Wiley-Blackwell , 2009, 43-56 p.Chapter in book (Other academic)
  • 11.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK.
    Dykes, Fiona
    University of Central Lancashire.
    ‘Being in a womb’ or ‘playing musical chairs’: the impact of place and space on infant feeding in NICUs2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, 179Article in journal (Refereed)
    Abstract [en]

    Background: Becoming a parent of a preterm baby requiring neonatal care constitutes an extraordinary life situation in which parenting begins and evolves in a medical and unfamiliar setting. Although there is increasing emphasis within maternity and neonatal care on the influence of place and space upon the experiences of staff and service users, there is a lack of research on how space and place influence relationships and care in the neonatal environment. The aim of this study was to explore, in-depth, the impact of place and space on parents’ experiences and practices related to feeding their preterm babies in Neonatal Intensive Care Units (NICUs) in Sweden and England.

    Methods: An ethnographic approach was utilised in two NICUs in Sweden and two comparable units in England, UK. Over an eleven month period, a total of 52 mothers, 19 fathers and 102 staff were observed and interviewed. A grounded theory approach was utilised throughout data collection and analysis.

    Results: The core category of ‘the room as a conveyance for an attuned feeding’ was underpinned by four categories: the level of ‘ownership’ of space and place; the feeling of ‘at-homeness’; the experience of ‘the door or a shield’ against people entering, for privacy, for enabling a focus within, and for regulating socialising and the; ‘window of opportunity’. Findings showed that the construction and design of space and place was strongly influential on the developing parent-infant relationship and for experiencing a sense of connectedness and a shared awareness with the baby during feeding, an attuned feeding.

    Conclusions: If our proposed model is valid, it is vital that these findings are considered when developing or reconfiguring NICUs so that account is taken of the influences of spatiality upon parent’s experiences. Even without redesign there are measures that may be taken to make a positive difference for parents and their preterm babies.

  • 12.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dykes, Fiona
    Creating a positive place and space in NICUs2014In: The Practising Midwife, ISSN 1461-3123, Vol. 17, no 7, 18-20 p.Article in journal (Other (popular science, discussion, etc.))
  • 13.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Chinese University of Hong Kong, Hong Kong; Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom.
    Dykes, Fiona
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), University of Central Lancashire, United Kingdom; Chinese University of Hong Kong, Hong Kong; University of Western Sydney, Australia .
    Cross-national ethnography in neonatal intensive care units2015In: Ethnographic Research in Maternal and Child Health / [ed] Fiona Dykes and Renée Flacking, Taylor & Francis, 2015, 89-116 p.Chapter in book (Other academic)
  • 14.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dykes, Fiona
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Encouraging breastfeeding: a relational perspective2010In: Early Human Development, ISSN 0378-3782, E-ISSN 1872-6232, Vol. 86, no 11, 733-736 p.Article in journal (Refereed)
    Abstract [en]

    Despite the WHO recommendations that babies should be breastfed exclusively for six months and thereafter for up to two years and beyond this pattern of feeding is far from the global norm. Although breastfeeding is triggered through biological mechanisms which have not changed with time, the perception of breastfeeding as a phenomenon is variable, as it not only reflects cultural values of motherhood but is also negotiable from the perspective of the individual. This paper argues that relationships are central to encouraging breastfeeding at an organisational, family and staff–parent level. This shifts our conceptualisations away from the primary focus of breastfeeding as nutrition which, in turn, removes the notion of breastfeeding as a productive process, prone to problems and failure.

  • 15.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dykes, Fiona
    Perceptions and experiences of using a nipple shield among parents and staff: an ethnographic study in neonatal units2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, no 1Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Preterm infants have an immature sucking behavior and the capacity to be exclusively breastfed may be reduced for a period of weeks or months, depending on gestational age. Nipple shields have been used, not only as a device to help mothers with sore nipples, but also to facilitate the infant's latch on to the breast. However, the benefits of using nipple shields have been debated. The aim of this study was to explore perceptions and experiences of using a nipple shield among parents and staff in neonatal units in Sweden and England.

    METHODS: An ethnographic study was undertaken where observations and interviews were conducted in four neonatal units in Sweden and England. The data were analyzed using a thematic networks analysis.

    RESULT: The global theme was developed and named, 'Nipple shield in a liminal time'. This comprised of two organizing themes: 'Relational breastfeeding' and 'Progression'. 'Relational breastfeeding' was underpinned by the basic themes, 'good enough breast', 'something in between' and 'tranquil moment'. 'Progression' was underpinned by the basic themes, 'learning quicker', 'short-term solution' and 'rescue remedy'. Although breastfeeding was seen primarily as a nutritive transaction, the relational aspects of breastfeeding were of crucial importance. These two organizing themes show the tension between acknowledging the relational aspects of breastfeeding and yet facilitating or supporting the progression of breastfeeding in the period from tube feeding or cup feeding to breastfeeding. It is a liminal time as mothers and their infants are "in between" phases and the outcome, in terms of breastfeeding, is yet to be realized.

    CONCLUSION: This study demonstrates parents' and staffs' perceptions of the nipple shield as a short term solution to help initiation of breastfeeding but also as a barrier between the mother and infant. It is important that the mother and baby's own particular needs are taken into account, in a person-centred way and on an ongoing basis. Furthermore, we need to emphasise the importance of the 'relational' whilst understanding the need for 'progression'. Holding these in balance may be the key to appropriate use of the nipple shield.

  • 16.
    Flacking, Renée
    et al.
    Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden; Center for Clinical Research Dalarna, SE-791 82 Falun, Sweden; Department of Paediatrics, Falun Hospital, SE-791 82 Falun Sweden.
    Dykes, Fiona
    Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Public Health and Clinical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK.
    Ewald, Uwe
    Department of Women's and Children's Health, Uppsala University, SE-751 85 Uppsala, Sweden.
    The influence of fathers’ socioeconomic status and paternity leave on breastfeeding duration: a population based cohort study2010In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 38, 337-343 p.Article in journal (Refereed)
    Abstract [en]

    Aim: The propensity to breastfeed is a matter of public concern because of the favourable effects for infants. However, very few studies have described the influence of paternal variables upon duration of breastfeeding. The aim of this study was to describe the effects of fathers’ socioeconomic status and their use of paternity leave on breastfeeding duration for infants up to 1 year of age. Methods: A prospective population-based cohort study was undertaken. Data on breastfeeding, registered in databases in two Swedish counties for 1993—2001, were matched with data on socioeconomic status and paternity leave obtained from Statistics Sweden. Fathers of 51,671 infants were identified and included. Results: Infants whose fathers had a lower level of education, were receiving unemployment benefit and/or had a lower equivalent disposable household income were significantly less likely to be breastfed at 2, 4, 6, 9, and 12 months of age. Infants whose fathers did not take paternity leave during the infant’s first year were significantly less likely to be breastfed at 2 (p < 0.001), 4 (p < 0.001), and 6 months (p < 0.001). Conclusions: This paper shows that an enabling of an increased involvement from fathers during the infants’ first year of life, such as by paid paternity leave, may have beneficial effects on breastfeeding up to 6 months of age. A more systematic approach to supporting fathers’ involvement may be particularly valuable to those infants whose fathers have a lower socioeconomic status.

  • 17.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Hedberg Nyqvist, Kerstin
    Starrin, Bengt
    Trustful bonds: A Key to “becoming a mother”and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit2006In: Social Science & Medicine, ISSN 0277-953, Vol. 62, no 1, 70-80 p.Article in journal (Refereed)
    Abstract [en]

    A preterm birth and subsequent hospitalization of an infant at a neonatal unit (NU) implies an extraordinary life situation for mothers, in which the maternal role and breastfeeding begin and evolve in a medical and unfamiliar setting. Descriptions of how women experience “becoming a mother” and breastfeeding in such a situation are sparse and this question was addressed in the present study. In this qualitative study, inspired by the grounded theory approach, in-depth interviews were conducted with 25 mothers whose very preterm infants had been cared for in seven NUs in Sweden. Findings indicated the importance of quality in social bonds with the infant, father, staff and other mothers at the NU, for “becoming mothers” and experiencing mutually satisfying breastfeeding. Three themes comprised a structure for descriptions of experiences, social bonds and mediated emotions: (1) ‘loss’ of the infant and the emotional chaos—“putting life on hold”; (2) separation—a sign of being unimportant as a person and mother; and (3) critical aspects of becoming more than a physical mother. The qualities were described as trustful or distrustful, characterized by accompanying feelings of pride/trust or shame/distrust. Social bonds were affected not only by the interpersonal interplay but also by the public environment and care routines. In conclusion, the contextual setting and distrustful social bonds impaired the ability to “become mothers” and the sensation of reciprocity i.e. breastfeeding becoming dutiful and not mutually satisfying. As breastfeeding is an intimate interplay and a personal choice it was considered that the best breastfeeding support would seem to be provision of a favorable environment that enhances the mother's confidence in herself. The contextual setting should be modeled such as to create conditions for a trustful and reciprocal mother–infant bond.

  • 18.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Starrin, Bengt
    “I wanted to do a good job”: Experiences of ‘becoming a mother’ and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit neonatal unit2007In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 64, no 12, 2405-2416 p.Article in journal (Refereed)
    Abstract [en]

    In mothers of preterm infants, the process of becoming a mother is initiated in a public and medical environment, in which the mothers become dependent on the benevolence and support of the staff. This setting and an experience of insecure social bonds impair the ability to become a mother during the infant's stay at the neonatal unit (NU), and breastfeeding may become a duty and not be mutually satisfying. Studies on how women experience becoming a mother and breastfeeding after the infant's discharge are sparse and this question is addressed in the present grounded theory study. Twenty five mothers, whose very preterm infants had received care in seven NUs in Sweden, were interviewed once, 1–12 months after discharge. We propose a model to increase understanding of the process of becoming a mother and breastfeeding, after the infant's discharge from the NU. The mother's emotional expressions in this process showed pendular swings from feeling emotionally exhausted to feeling relieved, from experiencing an insecure to a secure bond, and from regarding breastfeeding as being non-reciprocal to being reciprocal. Unresolved grief, the institutional authority at the NU and experiences of shame were three of the central barriers to a secure and reciprocal relationship. The pendular changes give us a deeper understanding of the variations in both attachment and attunement. Perhaps the negative extremes are more prominent among these mothers on account of their infant's illness and their NU experiences. If our proposed model is valid, it is vital that these findings are considered by those involved in the short- and long-term care in order to support the mothers to establish a secure bond, comprising both attachment and attunement.

  • 19.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Wallin, Lars
    Perinatal and socioeconomic determinants of breastfeeding duration in very preterm infants2007In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 96, no 8, 1126-1130 p.Article in journal (Refereed)
    Abstract [en]

    Aim: To describe the impact of prematurity, size at birth, neonatal disorders and the families' socioeconomic status (SES) on breastfeeding duration in mothers of very preterm infants.

    Methods: Prospective population-based cohort study. Data on breastfeeding, registered in databases in two Swedish counties in 1993–2001, were matched with data from two national registries: the Medical Birth Registry and Statistics Sweden. Mothers of 225 very preterm singleton infants were identified and included.

    Results: Seventy-nine percent of the mothers breastfed at 2 months, 62% at 4 months, 45% at 6 months, 22% at 9 months and 12% at 12 months. Prematurity, size at birth and neonatal disorders did not show an effect on breastfeeding duration. Being adversely exposed to any of the SES factors (maternal education, unemployment benefit, social welfare and equivalent disposable income in the household) was significantly associated with earlier weaning up to 6 months of infants' postnatal age.

    Conclusions: This study shows new and noteworthy results concerning breastfeeding duration in mothers of very preterm infants, which was not influenced by degree of prematurity, size at birth or neonatal disorders but was affected by SES. This highlights the need for improved support of socioeconomically disadvantaged mothers, during and after the hospital stay.

  • 20.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ewald, Uwe
    Wallin, Lars
    Karolinska Institutet.
    Positive effect of Kangaroo Mother Care on long-term breastfeeding in very preterm infants2011In: Journal of Obstetric, Gynecologic and Neonatal Nursing, ISSN 0884-2175, E-ISSN 1552-6909, Vol. 40, no 2, 190-197 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate the use of Kangaroo Mother Care (KMC) and its association with breastfeeding at 1 to 6 months of corrected age in mothers of very preterm (VPT) and preterm (PT) infants.

    Design: Prospective longitudinal study. Setting: Neonatal Intensive Care Units in four counties in Sweden. Participants: The study included 103 VPT (<32 gestational weeks) and 197 PT (32-36 gestational weeks) singleton infants and their mothers.

    Methods: Data on KMC, measured in duration of skin-to-skin contact/day during all days admitted to a neonatal unit, were collected using self-reports from the parents. Data on breastfeeding were obtained by telephone interviews.

    Results: VPT dyads that breastfed at 1, 2, 5, and 6 months had spent more time in KMC per day than those not breastfeeding at these times. A trend toward significance was noted at 3 and 4 months. In the PT dyads no statistically significant differences were found in the amount of KMC per day between those dyads that breastfed and those that did not.

    Conclusions: This study shows the importance of KMC during hospital stay for breastfeeding duration in VPT dyads. Hence, KMC has empowering effects on the process of breastfeeding, especially in those dyads with the smallest and most vulnerable infants.

  • 21.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hedberg Nyqvist, K
    Ewald, U
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Long-term duration of breastfeeding in Swedish low birth weight infants2003In: Journal of Human Lactation, ISSN 0890-3344, E-ISSN 1552-5732, Vol. 19, no 2, 157-165 p.Article in journal (Refereed)
  • 22.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hedberg Nyqvist, Kerstin
    Ewald, Uwe
    Effects of socioeconomic status on breastfeeding duration in mothers of preterm and term infants2007In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 17, no 6, 579-584 p.Article in journal (Refereed)
    Abstract [en]

    Background: The propensity to breastfeed is not only of importance with regard to the beneficial effects on the individual, but is also of concern as an indicator of health behaviour related to social conditions. Thus, our aim was to investigate the impact of socioeconomic status (SES) on breastfeeding duration in mothers of preterm and term infants.

    Methods: Prospective population based cohort study. Data for infants registered in breastfeeding databases of two Swedish counties 1993–2001 were matched with data from two national registries—the Medical Birth Registry and Statistics Sweden. A total of 37 343 mothers of 2093 preterm and 35 250 term infants participated.

    Results: All socioeconomic factors; maternal educational level, maternal unemployment benefit, social welfare and equivalent disposable income, were strongly associated with breastfeeding when examined individually in mothers of preterm and term infants. Some of the associations attenuated when investigated simultaneously. Independently of SES and confounders, mothers of preterm infants were at higher risk of weaning before the infant was 2 months (adjusted odds ratio (OR) 1.70; 95% confidence interval ((CI) 1.46–1.99)), 4 months (OR 1.79; CI 1.60–2.01), 6 months (OR 1.48; CI 1.33–1.64), and 9 months old (OR 1.19; CI 1.06–1.34), compared with mothers of term infants.

    Conclusions: In Sweden, despite its social welfare support system and a positive breastfeeding tradition, SES clearly has an impact on the breastfeeding duration. Mothers of preterm infants breastfeed for a shorter time compared with mothers of term infants, even when adjustments are made for SES and confounders.

  • 23.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Jerdén, Lars
    Bergström, Erik
    Starrin, Bengt
    "In or out": on the dynamic between acceptance and rejection and the influence on perceived health in adolescent girls2014In: Young - Nordic Journal of Youth Research, ISSN 1103-3088, E-ISSN 1741-3222, Vol. 22, no 3, 291-301 p.Article in journal (Refereed)
    Abstract [en]

    Adolescent girls' subjective health, or well-being, is of international concern as the frequency of psychological and psychosomatic complaints is continuously increasing in several countries world-wide. The causes of this development are still obscure. The aim of this study was to explore well-being and strategies for increased well-being among adolescent girls. Grounded Theory method was used, in which in-depth interviews were held with 18 adolescent girls, 17-18 years of age. Results showed that striving for acceptance and avoiding rejection were central for their well-being. When rejection was experienced, emotions of stress-shame were recognized, a phenomena we call the stress-shame cycle. In the struggle to prevent rejection and to become accepted, the girls strived to boost their social attractiveness by impression management.

  • 24.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lehtonen, Liisa
    Thomson, Gill
    Axelin, Anna
    Ahlqvist, Sari
    Hall Moran, Victoria
    Ewald, Uwe
    Dykes, Fiona
    Closeness and separation in neonatal intensive care2012In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 101, no 10, 1032-1037 p.Article in journal (Refereed)
    Abstract [en]

    In this paper, we highlight the need for acknowledging the importance and impact of both physical and emotional closeness between the preterm infant and parent in the neonatal intensive care unit. Physical closeness refers to being spatially close and emotional closeness to parental feelings of being emotionally connected to the infant (experiencing feelings of love, warmth and affection). Through consideration of the literature in this area, we outline some of the reasons why physical closeness and emotional closeness are crucial to the physical, emotional and social well-being of both the infant and the parent. These include positive effects on infant brain development, parent psychological well-being and on the parent–infant relationship. The influence of the neonatal unit environment and culture on physical and emotional closeness is also discussed.

    Conclusions:  Culturally sensitive care practices, procedures and the physical environment need to be considered to facilitate parent–infant closeness, such as through early and prolonged skin-to-skin contact, family-centred care, increased visiting hours, family rooms and optimization of the space on the units. Further research is required to explore factors that facilitate both physical and emotional closeness to ensure that parent–infant closeness is a priority within neonatal care.

  • 25.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Thomson, Gill
    Axelin, Anna
    Pathways to emotional closeness in neonatal units - a cross-national qualitative study.2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, no 1, 170Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Research shows evidence for the importance of physical and emotional closeness for the infant, the parent and the infant-parent dyad. Less is known about how, when and why parents experience emotional closeness to their infants in a neonatal unit (NU), which was the aim of this study.

    METHODS: A qualitative study using a salutogenic approach to focus on positive health and wellbeing was undertaken in three NUs: one in Sweden, England and Finland. An 'emotional closeness' form was devised, which asked parents to describe moments/situations when, how and why they had felt emotionally close to their infant. Data for 23 parents of preterm infants were analyzed using thematic networks analysis.

    RESULTS: A global theme of 'pathways for emotional closeness' emerged from the data set. This concept related to how emotional, physical, cognitive and social influences led to feelings of emotional closeness between parents and their infants. The five underpinning organising themes relate to the: Embodied recognition through the power of physical closeness; Reassurance of, and contributing to, infant wellness; Understanding the present and the past; Feeling engaged in the day to day and Spending time and bonding as a family.

    CONCLUSION: These findings generate important insights into why, how and when parents feel emotionally close. This knowledge contributes to an increased awareness of how to support parents of premature infants to form positive and loving relationships with their infants. Health care staff should create a climate where parents' emotions and their emotional journey are individually supported.

  • 26.
    Flacking, Renée
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK ; Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Thomson, Gill
    University of Central Lancashire.
    Ekenberg, Linda
    Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK.
    Löwegren, Linda
    Maternal and Infant Nutrition and Nurture Unit (MAINN), School of Health, University of Central Lancashire, Preston, Lancashire, UK.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
    Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants2013In: Sexual & Reproductive HealthCare, ISSN 1877-5756, Vol. 4, no 3, 107-112 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate the influence of co-care facilities and amount of skin-to-skin contact during Neonatal Intensive Care Unit (NICU) stay on maternal stress in mothers of preterm infants at two months corrected age.

    Methods:  A prospective cohort study that involved 300 mothers of pre-term infants was conducted in four NICUs (two with co-care facilities and two with non co-care) in Sweden. Data on duration of skin-to-skin contact per day for all days admitted to the NICU were collected using self-reports. Maternal stress was measured by the Swedish Parental Stress Questionnaire (SPSQ) at two months of infant’s corrected age.

    Results: Mothers whose infants were cared for in a NICU with co-care facilities reported significantly lower levels of stress in the dimension of ‘incompetence’ compared to mothers whose infants had been cared for in non co-care NICUs.  The amount of skin-to- skin experienced during the neonatal stay was not significantly associated with levels of maternal stress at two months corrected age.

    Conclusion:  The finding that mothers who do not experience co-care facilities experience greater levels of stress in relation to feelings of incompetence is of concern. Improvements to NICU environments are needed to ensure that mother-infant dyads are not separated.

  • 27. Jerdén, Lars
    et al.
    Hillervik, Charlotte
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hansson, Ann-Christin
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Weinehall, Lars
    Experiences of Swedish community health nurses working with health promotion and a patient-held health record2006In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 20, no 4, 448-454 p.Article in journal (Refereed)
    Abstract [en]

    Community health nurses have a tradition of preventive care, and might therefore be a key group in the introduction of new health-promotion methods. The aim of this study was to describe Swedish community health nurses' experiences in working with health promotion and a patient-held record as an integrated tool in their health-promotion work. Interviews were performed with 12 nurses at primary healthcare centres in the county of Dalarna, Sweden. A qualitative content analysis applying aspects of the grounded theory approach was performed. Central to the analysis was the nurses' struggle for balance, in being both a doer of practical disease-oriented tasks and a health-promotion communicator. Descriptions of the nurses' struggles to balance their work were grouped into three themes: (i) working alone and as a part of a team; (ii) nurse-related and patient-related interests; and (iii) patient's responsibility and shared responsibility between patient and nurse. The findings indicated that the structural organization in the primary healthcare centres was important for the community health nurses' means to work with health promotion and the patient-held record. In addition, the community health nurses' cognitive and emotional needs also affected this balance. in conclusion, the struggle of community health nurses to find a balance between being doers and health-promotion communicators is valuable in understanding health promotion in primary health care. The study indicates that it is not enough to develop health-promotion methods acceptable to community health nurses. A comprehensive examination of working conditions and the content of daily work is needed to ensure an emphasis on health promotion, including long-term usage of patient-held records.

  • 28. Joffer, Junia
    et al.
    Jerdén, Lars
    Öhman, Ann
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Exploring self-rated health among adolescents: a think-aloud study2016In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, 156Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite extensive use of self-rated health questions in youth studies, little is known about what such questions capture among adolescents. Hence, the aim of this study was to explore how adolescents interpret and reason when answering a question about self-rated health.

    METHODS: A qualitative study using think-aloud interviews explored the question, "How do you feel most of the time?", using five response options ("Very good", "Rather good", "Neither good, nor bad", "Rather bad", and "Very bad"). The study involved 58 adolescents (29 boys and 29 girls) in lower secondary school (7th grade) and upper secondary school (12th grade) in Sweden.

    RESULTS: Respondents' interpretations of the question about how they felt included social, mental, and physical aspects. Gender differences were found primarily in that girls emphasized stressors, while age differences were reflected mainly in the older respondents' inclusion of a wider variety of influences on their assessments. The five response options all demonstrated differences in self-rated health, and the respondents' understanding of the middle option, "Neither good, nor bad", varied widely. In the answering of potential sensitive survey questions, rationales for providing honest or biased answers were described.

    CONCLUSIONS: The use of a self-rated health question including the word 'feel' captured a holistic view of health among adolescents. Differences amongst response options should be acknowledged when analyzing self-rated health questions. If anonymity is not feasible when answering questions on self-rated health, a high level of privacy is recommended to increase the likelihood of reliability.

  • 29.
    Osman, Fatumo
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Schön, Ulla-Karin
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Ladnaan - att må bra: En utvärdering av ett riktat stöd till somaliska föräldrar i Borlänge Kommun2015Report (Other academic)
    Abstract [sv]

    Folkhälsomyndigheten har finansierat ett samarbetsprojekt mellan Borlänge kommun och Högskolan Dalarna för att anpassa och implementera ett föräldrastödsprogram till somaliska föräldrar, samt att mäta effekten av denna intervention avseende föräldrars och barns psykiska hälsa. Studien började med en explorativ delstudie med syfte att samla kunskap om vad somaliska föräldrar upplever som utmanande i sitt föräldraskap i Sverige, vilket behov av föräldrastöd de behöver samt hur ett sådant stöd ska vara utformat. Studien genomfördes med hjälp av fokusgruppsintervjuer med 23 föräldrar (15 mammor och 8 pappor) boende i Borlänge. Resultatet visade att föräldrarna upplevde en rad utmaningar i sin nya livssituation och i sitt föräldraskap i nya landet. De beskrev skillnader i synsätt på barnuppfostran och föräldraskap mellan hemlandet och Sverige och eftersträvade därför att kulturanpassa sitt föräldraskap.

    Resultaten från denna studie samt en genomgång av forskning kring föräldrastöd låg till grund för valet av föräldrastödsprogram samt ett samhällsorienterande tillägg till programmet.

     

    Målgrupp för studien var föräldrar med barn i åldrarna 11-16 år och som upplevde stress i sitt föräldraskap. Föräldrarna erbjöds sammanlagt 16 timmars utbildning fördelat på 12 träffar (10 timmar Connect föräldrastöd + 6 timmar samhällsorienterande tillägg). Effekten av föräldrastödet undersöktes genom en randomiserad kontrollerad studie där totalt 120 föräldrar ingick. De preliminära resultaten visar att deltagande föräldrars barn har förbättrats signifikant i subskalorna ”socialt” och ”skola”. Dessutom minskade barnens oro, somatiska problem, sociala problem och brytande av regler.

     

    Föräldrarna var nöjda med interventionen. De upplevde att de fått en ökad kunskap om hur socialtjänstens arbete fungerar och fått förtroende för deras arbete kring barn och unga. Över hälften av föräldrarna upplevde sig mer säkra i sin föräldraroll och att deras relation med barnen hade förbättrats.

     

    Genom en processutvärdering av implementeringen av föräldrastödet har framgångsfaktorer för genomförandet avföräldrastödsprogrammet studerats. Resultatet visade att de olika strategier som vidtagits vid rekrytering av föräldrar och implementering av interventionen har varit lyckade. Exempel på sådana strategier har varit att projektmedarbetarna som rekryterat till föräldrastödet har varit av Somaliskt ursprung, kursen har getts på somaliska men framförallt att föräldrastödet utgick ifrån föräldrarnas upplevda behov.

  • 30.
    Osman, Fatumo
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Dalarna University, School of Education, Health and Social Studies, Medical Science.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Schön, Ulla-Karin
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    A support program for Somali-born parents on children's behavioral problems2017In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 139, no 3Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The objectives of this study were to evaluate a culturally tailored parenting support program (Ladnaan) for Somali-born parents and to determine its effectiveness on children’s emotional and behavioral problems.

    METHODS: This randomized controlled trial included 120 Somali-born parents with children aged 11 to 16 years. The parents reported self-perceived stress in relation to parenting practices. The intervention consisted of culturally tailored societal information combined with the parenting program Connect. Parents received 12 weeks of intervention, 1 to 2 hours each week, in groups of 12 to 17 parents. Nine group leaders with a Somali background who received a standardized training program delivered the intervention. The primary outcome was a decrease in emotional and behavioral problems based on a Child Behavior Checklist. Parents were randomly allocated either to an intervention group or a wait-list control group. Covariance analyses were conducted according to intention-to-treat principles.

    RESULTS: The results showed significant improvement in the children in the intervention group for behavioral problems after a 2-month follow-up. The largest effect sizes according to Cohen’s d were in aggressive behavior (95% confidence interval [CI], 1.06 to 3.07), social problems (95% CI, 0.64 to 1.70), and externalizing problems (95% CI, 0.96 to 3.53).

    CONCLUSIONS: The large effect sizes in this study show that this 12-week culturally tailored parenting support program was associated with short-term improvements in children’s behavior. The study adds to the field of parenting interventions by demonstrating how to culturally tailor, engage, and retain parenting programs for immigrant parents.

  • 31.
    Osman, Fatumo
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Schön, Ulla-Karin
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Effectiveness of parenting support to Somali parents on children’s mental health: A randomized controlled trial2016Conference paper (Refereed)
  • 32.
    Osman, Fatumo
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Dalarna University, School of Education, Health and Social Studies, Medical Science.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Schön, Ulla-Karin
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    The impact of a culturally tailored parenting support for Somali-born parents’ and children’s mental health: A randomized controlled trial2017Conference paper (Refereed)
  • 33.
    Osman, Fatumo
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Schön, Ulla-Karin
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Parenthood in transition: Somali-born parents' experiences of and needs for parenting support programmes2016In: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 16, no 1, 82Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Pre- and post-migration trauma due to forced migration may impact negatively on parents' ability to care for their children. Little qualitative work has examined Somali-born refugees' experiences. The aim of this study is to explore Somali-born refugees' experiences and challenges of being parents in Sweden, and the support they need in their parenting.

    METHODS: A qualitative descriptive study was undertaken. Data were collected from four focus group discussions (FGDs) among 23 Somali-born mothers and fathers living in a county in central Sweden. Qualitative content analysis has been applied.

    RESULTS: A main category, Parenthood in Transition, emerged as a description of a process of parenthood in transition. Two generic categories were identified: Challenges, and Improved parenting. Challenges emerged from leaving the home country and being new and feeling alienated in the new country. In Improved parenting, an awareness of opportunities in the new country and ways to improve their parenting was described, which includes how to improve their communication and relationship with their children. The parents described a need for information on how to culturally adapt their parenting and obtain support from the authorities.

    CONCLUSIONS: Parents experienced a process of parenthood in transition. They were looking to the future and for ways to improve their parenting. Schools and social services can overcome barriers that prevent lack of knowledge about the new country's systems related to parenthood. Leaving the home country often means separation from the family and losing the social network. We suggest that staff in schools and social services offer parent training classes for these parents throughout their children's childhood, with benefits for the child and family.

  • 34.
    Randell, Eva
    et al.
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Jerdén, L.
    Öhman, A.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    What is health and what is important for its achievement?: A qualitative study on adolescent boys’ perceptions and experiences of health2016In: Open Nursing Journal, ISSN 1874-4346, E-ISSN 1874-4346, Vol. 10, 26-35 p.Article in journal (Refereed)
    Abstract [en]

    Few qualitative studies have explored adolescent boys’ perceptions of health.

    Aim: The aim of this study was therefore to explore how adolescent boys understand the concept of health and what they find important for its achievement

    Methods: Grounded theory was used as a method to analyse interviews with 33 adolescent boys aged 16 to 17 years attending three upper secondary schools in a relatively small town in Sweden.

    Results: There was a complexity in how health was perceived, experienced, dealt with, and valued. Although health on a conceptual level was described as ‘holistic’, health was experienced and dealt with in a more dualistic manner, one in which the boys were prone to differentiate between mind and body. Health was experienced as mainly emotional and relational, whereas the body had a subordinate value. The presence of positive emotions, experiencing self-esteem, balance in life, trustful relationships, and having a sense of belonging were important factors for health while the body was experienced as a tool to achieve health, as energy, and as a condition.

    Conclusion: Our findings indicate that young, masculine health is largely experienced through emotions and relationships and thus support theories on health as a social construction of interconnected processes. 

  • 35.
    Randell, Eva
    et al.
    Dalarna University, School of Education, Health and Social Studies, Social Work.
    Jerdén, Lars
    Öhman, Ann
    Starrin, Bengt
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Tough, sensitive and sincere: how adolescent boys manage masculinities and emotions2015In: International Journal of Adolescence and Youth, ISSN 0267-3843, E-ISSN 2164-4527, Vol. 21, no 4, 486-498 p.Article in journal (Refereed)
    Abstract [en]

    This study aimed to explore adolescent boys’ views of masculinity and emotion management and their potential effects on well-being. Interviews with 33 adolescent boys aged 16–17 years in Sweden were analysed using grounded theory. We found two main categories of masculine conceptions in adolescent boys: gender-normative masculinity with emphasis on group-based values, and non-gender-normative masculinity based on personal values. Gender-normative masculinity comprised two seemingly opposite emotional masculinity orientations, one towards toughness and the other towards sensitivity, both of which were highly influenced by contextual and situational group norms and demands, despite their expressions contrasting each other. Non-gender-normative masculinity included an orientation towards sincerity emphasising the personal values of the boys; emotions were expressed more independently of peer group norms. Our findings suggest that different masculinities and the expression of emotions are strongly intertwined and that managing emotions is vital for well-being.

  • 36.
    Randell, Eva
    et al.
    Dalarna University, School of Education, Health and Social Studies, Social Work. Umeå Universitet.
    joffer, Junia
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Starrin, Bengt
    Jerdén, Lars
    Associations between pride, shame and self-rated health in adolescence2016Conference paper (Other academic)
  • 37.
    Randell, Eva
    et al.
    Dalarna University, School of Education, Health and Social Studies, Social Work. Umeå Universitet.
    Joffer, Junia
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Starrin, Bengt
    Jerdén, Lars
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Umeå universitet; Uppsala universitet.
    Pride, shame and health among adolescents – a cross-sectional survey2017In: International Journal of Adolescent Medicine and Health, ISSN 0334-0139, E-ISSN 2191-0278Article in journal (Refereed)
  • 38. Thomson, Gill
    et al.
    Ebisch-Burton, Kate
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Shame if you do – shame if you don’t: women’s experiences of infant feeding2015In: Maternal and Child Nutrition, ISSN 1740-8695, E-ISSN 1740-8709, Vol. 11, no 1, 33-46 p.Article in journal (Refereed)
    Abstract [en]

    Emotions such as guilt and blame are frequently reported by non-breastfeeding mothers, and fear and humiliation are experienced by breastfeeding mothers when feeding in a public context. In this paper, we present new insights into how shame-related affects, cognitions and actions are evident within breastfeeding and non-breastfeeding women's narratives of their experiences. As part of an evaluation study of the implementation of the UNICEF UK Baby Friendly Initiative Community Award within two primary (community based) care trusts in North West England, 63 women with varied infant feeding experiences took part in either a focus group or an individual semi-structured interview to explore their experiences, opinions and perceptions of infant feeding. Using a framework analysis approach and drawing on Lazare's categories of shame, we consider how the nature of the event (infant feeding) and the vulnerability of the individual (mother) interact in the social context to create shame responses in some breastfeeding and non-breastfeeding mothers. Three key themes illustrate how shame is experienced and internalised through 'exposure of women's bodies and infant feeding methods', 'undermining and insufficient support' and 'perceptions of inadequate mothering'. The findings of this paper highlight how breastfeeding and non-breastfeeding women may experience judgement and condemnation in interactions with health professionals as well as within community contexts, leading to feelings of failure, inadequacy and isolation. There is a need for strategies and support that address personal, cultural, ideological and structural constraints of infant feeding.

  • 39. Thomson, Gill
    et al.
    Moran, Victoria Hall
    Axelin, Anna
    Dykes, Fiona
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Integrating a sense of coherence into the neonatal environment2013In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 13, 84Article in journal (Refereed)
    Abstract [en]

    Background: Family centred care (FCC) is currently a valued philosophy within neonatal care; an approach that places the parents at the heart of all decision-making and engagement in the care of their infant. However, to date, there is a lack of clarity regarding the definition of FCC and limited evidence of FCCs effectiveness in relation to parental, infant or staff outcomes.

    Discussion: In this paper we present a new perspective to neonatal care based on Aaron Antonovksy's Sense of Coherence (SOC) theory of well-being and positive health. Whilst the SOC was originally conceptualised as a psychological-based construct, the SOCs three underpinning concepts of comprehensibility, manageability and meaningfulness provide a theoretical lens through which to consider and reflect upon meaningful care provision in this particular care environment. By drawing on available FCC research, we consider how the SOC concepts considered from both a parental and professional perspective need to be addressed. The debate offered in this paper is not presented to reduce the importance or significance of FCC within neonatal care, but, rather, how consideration of the SOC offers the basis through which meaningful and effective FCC may be delivered. Practice based implications contextualised within the SOC constructs are also detailed.

    Summary: Consideration of the SOC constructs from both a parental and professional perspective need to be addressed in FCC provision. Service delivery and care practices need to be comprehensible, meaningful and manageable in order to achieve and promote positive well-being and health for all concerned.

  • 40.
    Östlund, Åsa
    et al.
    Falun Cent Hosp, Neonatal Unit, Falun, Sweden.
    Nordström, Maria
    Falun Cent Hosp, Paediat Unit, Dept Paediat, Falun, Sweden.
    Dykes, Fiona
    Univ Cent Lancashire, Maternal & Infant Nutr & Nurture Unit, Preston PR1 2HE, Lancs, England.
    Flacking, Renée
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Univ Childrens Hosp, Dept Womens & Childrens Hlth, Uppsala, Sweden.
    Breastfeeding in preterm and term twins - maternal factors associated with early cessation: a population based study2010In: Journal of Human Lactation, ISSN 0890-3344, E-ISSN 1552-5732, Vol. 26, no 3, 235-241 p.Article in journal (Refereed)
    Abstract [en]

    There is an increasing trend in Australia and elsewhere for mothers to express breast milk. The purpose of this study was to explore breastfeeding women’s experiences of expressing breast milk. An anonymous online questionnaire was sent to Victorian members of the Australian Breastfeeding Association via an e-mail link. Response fraction was 903 of 3024 (29.9%). The most common reason for expressing milk was to “store extra breast milk” (57%, 479/836). The most important reason was “not enough milk”/“to make more milk” (15%, 118/771). The majority of women (65%, 666/843) used an electric breast pump, and this method of expressing was preferred by 59% (454/769) of women. Adverse effects of pumps were pain (17%, 126/737) and damage to nipples (11%, 86/737). Breast pumps may have a role in enabling women to extend the duration of breast milk feeding, but further research is needed. J Hum Lact. 26(3):258-265.

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