Abstract
We researched alongside older Australian women who were newly diagnosed with type II diabetes. This inquiry was guided by Koch and Kralik’s participatory action research (PAR) methodology. We asked women to talk about their self-management and learning post-diagnosis and continued to talk with them for 12 months. Once we had built relationships we asked women to join group discussion. Ten PAR group sessions were held over six months. The focus of this article will privilege the group discussion led by the women so that group dynamics can be observed. We turn to Lewin and Tuckmann’s work on group dynamics and line up Koch and Kralik’s ‘look, think and act’ process as useful in describing what happens in a group. We suggest that a closer look at the group’s working reveals a better understanding of its democratic process, and that the theoretical models provide tools for closer scrutiny. The cyclical nature of the PAR process promoted reflection and learning among women. Women learnt more about diabetes and themselves through mutual engagement and self-directed activities. We conclude that group learning was a powerful dynamic in helping women to live with a chronic illness.
Introduction
The first line of treatment for people diagnosed with mature onset diabetes (type II), is a change in diet and an increase in exercise to promote the uptake and utilization of glucose. When first diagnosed, people tend to be overwhelmed by the immediate changes they have to make in their lives. The research question was how do older women, who are newly diagnosed with diabetes, learn to live with their condition during the first year post-diagnosis? Ethical approval was granted by the university where the first author was enrolled in her PhD.
There were two distinct phases of Koch and Kralik’s (2006) participatory action research (PAR) inquiry: storytelling (ongoing one-to-one interviews) and PAR group sessions to answer the research question. One-to-one interviews with community dwelling women were ongoing. Eleven women were interviewed for one year, and before they joined the PAR group, they were in receipt of co-constructed accounts of their lives in learning to live with diabetes. In this article we discuss phase two, where we held 10 PAR group sessions, which took place over six months. We understood that the PAR process usually results in personal development or even in group reform, sometimes both (Koch & Kralik, 2006). What actually happens in the group as it moves toward reform has not been described in depth. This is the objective of this article. We will show group dynamics evident during the PAR process and describe ‘reform’ movement as women learn collaboratively in a group.
Background
Over the last 20 years, Koch and Kralik have facilitated participatory action inquiries in health care with community members, professionals, managers, educators and participants. They have completed more than 40 studies aimed at developing participative problem-solving in communities; explored with indigenous people their stories of living with chronic illness; and researched alongside people with muted and suppressed voices such as those living with mental illness or women who were sexually abused as children. However, their main program of research has been with people living with a chronic illness (Koch & Kralik, 2006). These researchers used action research approaches to explore disruptive events when a chronic illness invades people’s lives and, in collaboration with patients, develop ways that people can transition through the event and create a sense of continuity in their lives. The ability to make a difference to people’s lives has been the major driving force. What has been noticeable in their experience of the PAR process has been the growth and development of all involved. Importantly, their research focus has not always been the identification and dwelling with issues. PAR principles have been directed towards articulating strengths and the dreams and themes of ‘what could be’. Being involved in the PAR process has many benefits as people experience a growth and learning process. Individual and group reform has resulted in human flourishing. Participants have benefited from exposure to the PAR process. When we embarked on this inquiry we expected no less. Although Kokanvic and Manderson (2006) highlighted the role of group learning in diabetes, they did not investigate such learning in depth.
Group dynamics: Review of the literature
Prior to going in the field, the first author read widely around group dynamics as it was certain to be imperative in understanding and facilitating the PAR group, phase two of this inquiry. Group process refers to the understanding of the behaviour of people in groups as the group tries to solve a problem or make a decision (Koch & Kralik, 2001). By studying group processes it should be possible to enhance group effectiveness and functioning. The seminal texts written by Lewin (1947) and Tuckman (1964) provided good information about groups.
Whilst the body of literature on group development revealed a wide range of theoretical models concerning developmental processes, group dynamics is the study of small groups, and also a general term for group processes (Tuckman & Jensen, 1977). These processes include norms, roles, relations, development, need to belong, social influence and effects on behaviour (Kokanovic & Manderson, 2006).
Groups appear to go through a number of phases/stages if they continue to meet for an extended time. The most influential model is from psychology, Tuckman’s (1964) forming, storming, norming and performing. The first, forming refers to orientation and introductory activities that constitute the group process. The second, storming, is characterized by conflict and polarization around interpersonal issues. Storming is often a confrontational experience when participants let down the politeness barrier. This resistance is overcome in the third stage in which in-group feeling and cohesiveness develop and this is termed norming. In the norming stage participants become used to each other and start to develop trust and toward productivity. The fourth stage shows that interpersonal structures become evident and group energy is channelled into action and this stage is labelled as performing. Tuckman later suggested a fifth stage called ‘adjourning’ (Tuckman & Jensen, 1977). Adjourning involves dissolution or when the group disbands. Forsyth (2006) described this stage as ‘mourning’ given the loss that is sometimes felt by former participants. Tuckman maintained that these phases are all necessary and inevitable in order for the team to grow, to face up to challenges, to tackle problems, to find solutions, to plan work, and to deliver results. Tuckman’s model has become the basis for subsequent models.
Lewin’s (1947) work had a profound impact on our appreciation of experiential learning, group dynamics and action research. One of the legacies Lewin left us is the ‘action research spiral’; we use ‘look, think and act’ in this study’s version of PAR and also talk about it as a spiral. However, Lewin points out that action research is not a ‘method’ or a ‘procedure’ for research ‘but a series of commitments to observe and problematize through practice a series of principles for conducting social enquiry’ (McTaggart, 1997, p. 249). The Koch and Kralik (2006) PAR process is congruent with the need for commitment but avoids problematization; rather its focus is on strengths (both individual and group). Facilitators foster relationships among participants based on strengths in order for the group to move towards action.
Two key ideas emerged out of Lewin’s field theory that are crucial to an appreciation of group process: interdependence of fate (a group exists when people in it realize their fate depends on the fate of the group as a whole), and task interdependence (if the group’s task is such that members of the group are dependent on each other for achievement, then a powerful dynamic is created). However, Lewin argues that democratic principles must be learned anew in each generation and within each group. Therefore the setting of norms is crucial to learning democratic principles. One of the norms selected by participants is usually to have a voice and to represent oneself. Democratic leadership in groups has become deeply influential in action research. Two other key aspects are relevant in Lewin’s group dynamics: feedback and unfreezing.
Feedback is an essential aspect of fostering group dynamics. Feedback was found to ‘be most effective when it stemmed from here-and-now observations, when it followed the generating event as closely as possible, and when the recipient checked with other group members to establish its validity and reduce perceptual distortion’ (Yalom, 1995, p. 489). Feedback is a routine activity of the PAR cycle described by Koch and Kralik’s (2006) processes; after each one-to-one interview a storyline is created, the individual’s story is returned to the participants for verification, a group storyline is also created and presented to the group at the first meeting. Here the group story is verified and used a way of reflecting on common experiences. Before a PAR group recommences, each participant is given a summary of the previous meeting’s conversations and actions clearly identified.
Unfreezing describes the process of disconfirming a person’s former belief system. ‘Motivation for change must be generated before change can occur. One must be helped to re-examine many cherished assumptions about oneself and one’s relations to others’ (Lewin, 1947, p. 151).
There are more recent studies on participatory action research groups. For instance, according to Ciu (2003), a variety of focus group methods can be adapted not only to facilitate critical awareness-raising, but also as a systematic and focused way of managing the change process through problem-solving, decision-making and reflection. However, the claim to transformation in PAR, particularly when communicating such a claim to a wider research community, cannot be based solely on the use of specific methods (e.g. focus groups). It requires the critical reflection of the researcher on all levels of knowing and doing, and the critical description of the experiences of specific struggles fought by participants who wield other forms of power besides talk.
A significant problem with conventional interventions in the context of chronic conditions such as diabetes is that conventional interventions tend to be expert-driven and externally funded. As such they are not organizationally sustainable. Programs designed and maintained in such a manner are vulnerable when funding expires or when the principal (professional) leader of the initiative shifts his or her focus to another project, changes jobs, etc. (Mendenhall & Doherty, 2007).
Learning is best facilitated in an environment where inputs from each perspective are freely given and can be challenged. A learning environment occurs with remarkable vitality and creativity when democratic processes are honoured. Koch and Kralik (2006) use the term ‘learning circle’ to describe group interaction and learning. The facilitator’s attention is focused on the group’s ‘looking, thinking and acting’ when generating data and analysis. Most conflict is usually experienced in the ‘thinking’ phase where individuals wrestle with their personal ideas within the group process and skill is required to assist the members of the group to be heard, valued and to move on.
Methodology
Researching alongside participants in a group we followed the cyclical processes of ‘looking, thinking, and acting’ as an iterative process. The process of PAR is viewed as spirals of self-reflective cycles. Look, think and act describes this cycle where looking can be facilitated through asking participants to tell their story (Koch & Kralik, 2006). We ask: what is happening in each story, what have participants chosen to talk about, and what is important here? Group discussion and storytelling are analysed concurrently. Observations from the analysis are provided to participants as feedback. Although these steps are rarely linear, we invited participants to reflect on the feedback and continue with the story in subsequent interviews/group sessions. This is the thinking phase. Focusing on their lives and learning to live with diabetes often assisted participants to make their experiences accessible for reflection, discussion and reconstruction. The learning process can be observed in what women did, how they interacted in and with the world, what women meant and what they valued and the language used to describe their world.
PAR groups created movement. We monitored the actions created within the action phase of the cycle. Before the group met again we provided women with feedback as a summary of events and action that had taken place previously. We understood that the PAR process usually results in personal development or even in group reform, sometimes both. As discussed, Koch and Kralik’s (2006) PAR methodology was selected as this approach has been particularly productive in researching alongside people living with a chronic illness (Kralik, 2002; Koch, Jenkin, & Kralik, 2004).
Exploring group dynamics
Three models for exploring group dynamics.
Whilst there are many accounts of group process in education, psychology and in action research texts, very few actually take the reader inside a group. So much has been written about group dynamics but very little is experiential. In our study group dynamics can be observed during the cycles of ‘looking, thinking and acting’ in PAR, the latter being the reform that results as the outcome of the group.
The PhD candidate recruited women who had attended three diabetes education sessions provided by the local health service diabetes centre staff. Eleven older women volunteered to research alongside the first author for 18 months, with one-to-one interviews and subsequent group meetings.
PAR group participants
Eleven women, all those interviewed in the first year of the study, participated in 10 PAR group sessions. Women had been diagnosed with diabetes in the six months prior to the one-to-one interviews and PAR groups took place one year post-diagnosis. Their average age was 65 years and their actual age is shown in bracket next to their fictional name. Anna (81) married Chris 55 years ago and had seven children. Prior to being diagnosed Anna had two co-morbidities: arthritis and hypertension. Barbara (75) had been married to Bob a long time. Her other chronic condition was asthma. Bella (72) was married to Andrew. Alison (56) was still in the work force. Alison had a pre-existing breast cancer now in remission. Helen (58) was a divorcee, with three adult children, was living with her brother. She had a strong family history of diabetes. Elizabeth (62) was married with three adult children. Katy was a retired nurse (65) and divorced. Her co-morbidities were high blood pressure, arthritis and she had recently recovered from breast cancer treatment. Oral medications for diabetes were prescribed. Sara (69) was a divorcee living alone. She had a heart problem. Kathryn (55) was employed and lived with her mother and daughter. She had several co-morbidities: depression, kidney and thyroid problems. Kathryn was also prescribed oral medication for her diabetes. She had a family history of diabetes and was overweight when diagnosed. Rose (58) was married 33 years ago and had two daughters. Her brother and husband had diabetes. Pam (72) is a widower. She had four children. Sometimes her daughter Sally lived with her.
Preparation for PAR group meetings
It was important to be organized and prepared before each PAR group meeting. Preparation consisted of telephoning and personally inviting the women and their family members or friends to join each of the PAR group meetings and it was also important to create an accessible, comfortable and safe environment for meetings given that all of the participants were older women and dependent on others for travel. Ensuring all women had transportation to meetings was another aspect to be considered. Access to venue and use of space was confirmed with the diabetes nurse educator at the local health centre, a site that was familiar to the women as they had attended three diabetes classes when first diagnosed. Preparation also included agreeing to a suitable day and length of time for the meetings. Arranging seating in a circle before starting the PAR group meetings, providing appropriate refreshments for people with diabetes, and checking and re-checking the functioning of the digital audio recorder was also done. Ahead of time we negotiated an agenda for the meetings or we built an agenda collaboratively based discussions from the previous meetings. We consulted with the diabetes nurse consultant and the dietician at the health centre should our participants request additional diabetes management information. These health care professionals agreed to be on standby to join the group when requested.
PAR sessions
We met for 10 sessions, at fortnightly intervals, on Monday afternoons for two hours. Transcribing the meeting conversations added to the rigour of this study. The text was analysed concurrently and apart from observation, capture group dynamics. Aspects of the PAR group meetings were summarized. Before starting each group meeting summaries, consistent with Koch and Kralik (2006) and Lewin’s ‘feedback’ process, were distributed and their content validated by the group.
Setting the norms
During the first PAR group meeting we asked the participants to discuss the norms or ‘rules’ for working within this group. The women agreed to use their real names during the group meetings with each other and chose a fictional name for publication. At the first meeting the women agreed that the group was closed to all others except the PhD supervisors, the diabetes nurse educator and the dietician. Collectively, the women agreed that the group conversation were confidential and should not be disclosed outside the group. The other important rule set by the group was that all women agreed that each was entitled to express their ideas and should be given time for this. The women agreed to give each other an opportunity to speak and that only one person should talk at one time. Respect for each other was agreed upon; in particular, they agreed to respect another’s beliefs and point of views. In other words, diversity was to be honoured.
Building relationships
Although known to the researchers through one-to-one interviews during the previous 12 months, the women were strangers to each other. With this in mind, the researchers discussed the best way to build relationships in the group. When asked prior to the first PAR session, participants selected that we started with the common story rather than engage in individual storytelling, stating that it would be a more efficient use of their time. A common story was shared with participants.
The first PAR group meeting was held in the local health centre. The purpose of sharing the story was to stimulate discussion in the ‘looking’ phase. The idea that the common story would facilitate discussion about learning to live with diabetes was erroneous. There was some discussion about storytelling and also some misunderstandings. Elizabeth said that she did not come to the group meetings to hear other women’s stories; however, everybody started talking about their own story without interruption. We learned that there were multiple understandings about the notion of ‘story’. Once one had broken the ice, women listened. This may be viewed as the storming stage using Tuckman’s model or the ‘looking’ stage of Koch and Kralik’s model, however, the PAR ‘look, think and act’ process is rarely linear.
Interacting and ‘looking’ collaboratively meant taking control of their diabetes management which also meant being committed to changing their lifestyle. Participants set the agenda for meetings with much of the conversation about food, eating and dieting. Women shared information and understanding about low GI foods and recipes and they seriously encouraged and implored each other to diet and lose weight as is the requirement for those newly diagnosed with diabetes. For example, Barbara checked her blood sugar levels regularly, viewing it as a chore in her life. The other women in the group persuaded Barbara to continue monitoring her blood sugar level and explained to her that by checking she would know what was going in her body and that it would help her to decide how much carbohydrate she could consume. In this way, women interacted positively, and coached and advised others in the group. This type of interaction, potentially confronting for some given the nature of the advice, is similar to ‘unfreezing’ in Lewin’s terms.
At the third PAR group meeting, the women appeared to be more comfortable with each other or norming as Tuckman would call it whereas Koch ad Kralik would emphasize this was evidence of relationship building in the ‘looking’ phase. It was interesting that the major topic of conversation was still on food: its purchase, preparation and its dietary values. Researchers, when debriefing after the session, discussed the women’s preoccupation with food. Perhaps, we speculated, its continued focus was role driven as responsibility for food production is usually in a women’s terrain or women’s work.
The women reflected now on their learning and said that attending the three formal diabetes classes had increased their knowledge about diabetes but not everyone had been ready for the deluge of information so soon after being diagnosed. Indeed, some found it confusing and overwhelming. They noted that they would have liked an opportunity to relate the way they were managing their diabetes and ask questions when they were ‘ready’ for information and as it related to their need to know and understand or their stage of learning in relation to their diagnosis. Being ready to absorb information often coincided with the family dynamics: if women had close family support, if family members were also monitoring them and their response to the disease, they were ready to learn early on following their diagnosis. The importance of having a close family member to assist with adjusting to living with chronic illness was highly regarded by the women.
The women discovered that if they were already living with another chronic illness, such as cancer, the adjustments that they needed to make were not as problematic. Women with other co-morbidities appeared be ready for information sooner. Perhaps the first time someone is diagnosed with a chronic condition, the prospect of one’s mortality is foregrounded and inhibits one’s readiness to learn. Having other chronic illnesses prior to being diagnosed with diabetes may mean that women have dealt with their mortality concerns and they are emotionally ‘ready’ to learn about diabetes self-management sooner.
Also placed on the PAR group agenda was how to read and understand dietary labelling, such as sugar and carbohydrate quantities or GI indexes, on food packages. For this learning need, the group sought help from the diabetes nurse educator and the dietician. The women also requested a guided shopping session for appropriate ‘diabetic foods’ at the local supermarket. The ‘action’ coming out of this PAR group was about the collective need for a ‘shopping tour’ and learning to read labels.
Women brought books and magazines to the group sessions. In this ‘thinking’ phase, women offered their rationale for selecting certain books or magazines. Pam, Helen and Bella preferred to learn from easy to grasp books such as A traffic light book (Diabetes Australia, 2005) and Natural solutions for diabetes (Kuypers, 2005) and these books were recommended to the group. Alison and Barbara said they liked to read medically orientated books (Dunning, 2009) as they worked in health care or had previous medical knowledge. There is great diversity in the needs of people in terms of suitable reading material depending on previous exposure and experience. It seemed clear that women learn when a book or magazine is immediately accessible, that the language used is easily comprehended and that the content is meaningful and applicable. However, in the PAR group women were also collaborating with each other and in each other’s learning by sharing materials, knowledge and understanding and their personal insights, which is consistent with acting in PAR and Lewin’s action or reform.
It is interesting that women were still eager for ‘diabetes’ and lifestyle information one year following their diagnosis. At all meetings, the diabetes nurse educator or the dietician were on hand to answer any queries that the women had. It was during the first five PAR groups that their need for additional information and understanding was foregrounded. For example, Rose, Elizabeth and Katy benefitted from the discussion on carbohydrates during the PAR group. In particular, they had learned that they needed to take in fewer than 10 carbohydrate exchanges per day, something that they had not fully apprehended when they attended the diabetes education classes 12 months previously. Action and reform had occurred.
During the PAR group meetings, the women talked non-stop, sharing information and individual experiences. Relationships between the women were built irrespective of their backgrounds and education. We noticed that Rose, who did not talk much during the first sessions, appeared to grow in confidence as she talked and interacted with the other women more readily and easily over time. Rose shared her pride in losing weight through monitoring her food intake.
Armed with additional knowledge gained from the invited heath care professionals about exercise and food choices during the PAR group meetings, the women were able to contemplate losing weight and the ways to achieve this. They heard that they should eat less carbohydrate and do more exercise: we noticed that the women smiled and nodded their heads during these meetings. They seemed ready to take this information on board. At the sixth PAR meeting the women queued to weigh themselves on the scales in the centre and they continued to weigh themselves at later meetings; collaboratively they celebrated their weight loss over time. Women were performing using Tuckman’s model and ‘acting’ in the PAR model.
By the seventh PAR group session, the women placed exercise on the agenda once more; they wanted to talk about their own experiences. Barbara was walking for half an hour every day as well as exercising three days in the hydrotherapy pool, doing ‘heart moves’ and riding her bike. Pam and Elizabeth were proud of taking long walks. Katy and Rose preferred to go to a women’s only gym and claimed that they were more comfortable to do exercise in this environment. On the agenda of the eighth PAR session was diabetes self-management. Bella and Barbara had come to the conclusion that self-management was the combination of diet and exercise. And for the first time Katy, Anna and Kathryn spoke with the group about taking oral hypoglycaemic tablets and the role of medication. So far conversations had been a result of ‘thinking’ and we noticed many individual lifestyle changes had been made. Action had been taken at individual levels: arguably the women were acting, ‘performing’ and reforming.
At the final session of the PAR group, the women agreed that learning to live with diabetes was an ongoing life project. Helen, Rose and Bella believed that being in a group and interacting with each other was a powerful way to learn. They enjoyed the learning as it was based on what really they needed to take on board and it was done with people who had the same condition and concerns.
We had been meeting for six months and women were clearly comfortable with each other. Although we had prepared them, when we reminded them the project was nearing closure and that the next group session would be our last meeting, there was dismay. Tuckman and Jensen (1977) were later to call this adjournment. Regardless, women felt more relaxed and settled in comparison with six months earlier. Pam stated: I am grateful for attending this study. Belonging to this group meeting let me learn more about living with diabetes … It was good to get some support from the group and it encouraged me to keep going to look after myself. Learning to live with diabetes is a constant learning experience. It is not possible to learn everything just during the three diabetes classes. This is why I enjoyed attending these group meetings to reinforce my learning.
Reflection
Rather than leave our philosophy implicit (Goodyear, 2005) this participatory action research (PAR) was democratic and participative. Democracy has to be learned (Lewin, 1947) and this meant learning to be a democratic facilitator and appreciating that our participants determine the agenda, drive the research and decide on actions and/or reform. In addition, it was equally important that in order to be able to move forward as a group the women needed to interact as a cohesive group.
The PAR groups were facilitated in cooperation with supervisors. Together we focused on the strengths of individuals and the group. We noticed how women took control of the process and set the agenda. Occasionally, some comment or guidance from the facilitator was required, for example, whether it was time to have a break, but participants managed the process, particularly if someone talked too much or were too dominant; they were reminded of the norms. Norms had been established, the group as a whole kept itself ‘on track'.
The cyclical nature of the PAR process promoted reflection and learning that led to the enhancement of these women’s lives. We trusted the process and most importantly we trusted the power of the women sitting in the PAR learning circle. We avoided behaviours that could hinder group interaction: judging, controlling, superiority, certainty, indifference and manipulation. We became conversant with the fluidity of the ‘look, think and act’ processes and we learned about the skills necessary to capitalize on these ‘stages’ to accomplish forming a productive, cohesive group. Group dynamics was a critical factor in group performance. We constantly analysed whether the group was ‘looking, thinking or acting’ and pondered about ways in which we could motivate the group. We invited participants to ‘think’ about aspects of the story which helped refocus the energy of the circle from merely ‘looking’ to ‘thinking’ and eventually to stimulate action.
The value of research of this PAR process was to observe how participants coped with the new realities in their lives as a result of their learning within the group. It was shown that the women learnt through mutual engagement in activities, which was defined by the negotiation of meaning both inside the group and outside with health care professionals, or, what Fuller, Hodkinson, Hodkinson, and Unwin (2005) called legitimate peripheral learning. Health care professionals were invited on request and brought into the group. The organizing of diabetes self-management ideas was assisted through the medium of brief lectures and handouts. This was effective and demonstrates that the basic allegiance of the PAR group was to facilitate learning for its members.
PAR group sessions provided a really good opportunity for the health care professionals to see, for the first time, the way the women were continuing to learn post-diagnosis. Even after women’s attendance at three formal diabetes class sessions, health care professionals were intrigued, as were researchers, by the constant need for repetition of information. Involving diabetes centre staff in this way has alerted them to take alternative educational strategies into their diabetes classes, and is geared toward addressing objective five of this study. In addition, an open-door policy has been instigated by the health service, so that women can call the diabetes centre staff at any time in the future.
Conclusion
Although we knew that it was usual for a PAR group to reach out, act and reform situations collectively (Koch & Kralik, 2006) these women were engrossed with themselves and the immediate lifestyle modifications that they had to make. Absorbing new information at a rate that was compatible with individual learning styles was made clear through the group process.
Whilst in Tuckman’s model this appears to be a movement between the stages of norming and performing, we argue that relationship-building is central and accompanies all stages of the ‘look, think and act’ (LTA) model. In our experience, small groups tend to follow a fairly predictable path toward action, both individual and/or group. It was clear that women’s behaviour had changed and that learning had occurred in terms of managing diabetes much better; however, major reform as the resultant outcome of this PAR process did not happen. Individual action and personal growth was achieved. PAR group sessions served as a means to understanding the complexities of self-management with diabetes and of transitioning to a new lifestyle. Learning from each other in a group was a powerful dynamic towards a life-changing event.
In our effort to add to the theoretical conversation above, we recognized that group dynamics, or what happens in a group, is not often discussed in action research papers. Therefore we have taken the reader inside group dynamics in this PAR process with women and we have shown the way in which women learn collaboratively.
Footnotes
Acknowledgements
The first author would like to thank The University of Newcastle for awarding Postgraduate Scholarships as follows: The University of Newcastle Postgraduate Research Scholarship (UNUPRS) and University of Newcastle Postgraduate Research Scholarship External (UNRSE) Australia and the School of Nursing and Midwifery Scholarship for the last semester of enrolment. We also thank the Newcastle women who participated with us in this research study.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.