1
|
Masters C, Carandang RR, Lewis JB, Hagaman A, Metrick R, Ickovics JR, Cunningham SD. Group prenatal care successes, challenges, and frameworks for scaling up: a case study in adopting health care innovations. Implement Sci Commun 2024; 5:20. [PMID: 38439113 PMCID: PMC10913654 DOI: 10.1186/s43058-024-00556-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/12/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Group prenatal care enhances quality of care, improves outcomes, and lowers costs. However, this healthcare innovation is not widely available. Using a case-study approach, our objectives were to (1) examine organizational characteristics that support implementation of Expect With Me group prenatal care and (2) identify key factors influencing adoption and sustainability. METHODS We studied five clinical sites implementing group prenatal care, collecting qualitative data including focus group discussions with clinicians (n = 4 focus groups, 41 clinicians), key informant interviews (n = 9), and administrative data. We utilized a comparative qualitative case-study approach to characterize clinical sites and explain organizational traits that fostered implementation success. We characterized adopting and non-adopting (unable to sustain group prenatal care) sites in terms of fit for five criteria specified in the Framework for Transformational Change: (1) impetus to transform, (2) leadership commitment to quality, (3) improvement initiatives that engage staff, (4) alignment to achieve organization-wide goals, and (5) integration. RESULTS Two sites were classified as adopters and three as non-adopters based on duration, frequency, and consistency of group prenatal care implementation. Adopters had better fit with the five criteria for transformational change. Adopting organizations were more successful implementing group prenatal care due to alignment between organizational goals and resources, dedicated healthcare providers coordinating group care, space for group prenatal care sessions, and strong commitment from organization leadership. CONCLUSIONS Adopting sites were more likely to integrate group prenatal care when stakeholders achieved alignment across staff on organizational change goals, leadership buy-in, and committed institutional support and dedicated resources to sustain it. TRIAL REGISTRATION The Expect With Me intervention's design and hypotheses were preregistered: https://clinicaltrials.gov/study/NCT02169024 . Date: June 19, 2014.
Collapse
Affiliation(s)
- Claire Masters
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Rogie Royce Carandang
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, 06030, USA
| | - Jessica B Lewis
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06519, USA
| | - Ashley Hagaman
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, 06510, USA
- Center for Methods in Implementation and Prevention Sciences, Yale University, New Haven, CT, 06510, USA
| | - Rebecca Metrick
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, 06510, USA
- Sinai Urban Health Institute, Chicago, IL, 60608, USA
| | - Jeannette R Ickovics
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Shayna D Cunningham
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, 06030, USA.
| |
Collapse
|
2
|
Martens N, Hindori-Mohangoo AD, Hindori MP, Damme AV, Beeckman K, Reis R, Crone MR, van der Kleij RR. Anticipated benefits and challenges of implementing group care in Suriname's maternity and child care sector: a contextual analysis. BMC Pregnancy Childbirth 2023; 23:592. [PMID: 37596532 PMCID: PMC10436662 DOI: 10.1186/s12884-023-05904-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/07/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Suriname is a uppermiddle-income country with a relatively high prevalence of preventable pregnancy complications. Access to and usage of high-quality maternity care services are lacking. The implementation of group care (GC) may yield maternal and child health improvements. However, before introducing a complex intervention it is pivotal to develop an understanding of the local context to inform the implementation process. METHODS A context analysis was conducted to identify local needs toward maternity and postnatal care services, and to assess contextual factor relevant to implementability of GC. During a Rapid Qualitative Inquiry, 63 online and face-to-face semi-structured interviews were held with parents, community members, on-and off-site healthcare professionals, policy makers, and one focus group with parents was conducted. Audio recordings were transcribed in verbatim and analysed using thematic analysis and Framework Method. The Consolidated Framework for Implementation Research served as a base for the coding tree, which was complemented with inductively derived codes. RESULTS Ten themes related to implementability, one theme related to sustainability, and seven themes related to reaching and participation of the target population in GC were identified. Factors related to health care professionals (e.g., workload, compatibility, ownership, role clarity), to GC, to recipients and to planning impact the implementability of GC, while sustainability is in particular hampered by sparse financial and human resources. Reach affects both implementability and sustainability. Yet, outer setting and attitudinal barriers of health professionals will likely affect reach. CONCLUSIONS Multi-layered contextual factors impact not only implementability and sustainability of GC, but also reach of parents. We advise future researchers and implementors of GC to investigate not only determinants for implementability and sustainability, but also those factors that may hamper, or facilitate up-take. Practical, attitudinal and cultural barriers to GC participation need to be examined. Themes identified in this study will inspire the development of adaptations and implementation strategies at a later stage.
Collapse
Affiliation(s)
- Nele Martens
- Leiden University Medical Center, Leiden, the Netherlands.
| | | | - Manodj P Hindori
- Foundation for Perinatal Interventions and Research in Suriname (Perisur), Paramaribo, Suriname
| | - Astrid Van Damme
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
| | - Katrien Beeckman
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
- Centre for Research and Innovation in Care, Universiteit Antwerpen, Antwerp, Belgium
| | - Ria Reis
- Leiden University Medical Centre, Leiden, Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, Netherlands
- University of Cape Town, Cape Town, South Africa
| | | | | |
Collapse
|
3
|
Moyett JM, Ramey-Collier K, Zambrano Guevara LM, MacDonald A, Kuller JA, Wheeler SM, Dotters-Katz SK. CenteringPregnancy: A Review of Implementation and Outcomes. Obstet Gynecol Surv 2023; 78:490-499. [PMID: 37594439 DOI: 10.1097/ogx.0000000000001169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Importance CenteringPregnancy (CP) is a model for group prenatal care associated with improved perinatal outcomes for preterm birth and low birthweight, increased rates of breastfeeding, and higher rates of patient and clinician satisfaction. Objective The study aims to review the literature related to perinatal outcomes associated with CP, benefits and barriers to implementation, and utility of the model. Evidence An electronic-based search was performed in PubMed using the search terms "CenteringPregnancy" OR "Centering Pregnancy," revealing 221 articles. Results The CP model improves patient centeredness, efficiency, and equality in prenatal care. Challenges include administrative buy-in, limited resources, and financial support. Multisite retrospective studies of CP demonstrate improved maternal, neonatal, postpartum, and well-being outcomes, especially for participants from minority backgrounds; however, prospective studies had mixed results. CenteringPregnancy is feasibly implemented with high tenet fidelity in several low- and middle-income settings with improved perinatal outcomes compared with traditional care. Conclusions CenteringPregnancy is feasible to implement, largely accepted by communities, and shows positive qualitative and quantitative health outcomes. This body of literature supports CP as a potential tool for decreasing racial inequalities in prenatal access, quality of care, and maternal mortality. Further investigation is necessary to inform obstetric clinicians about the potential outcome differences that exist between group and traditional prenatal care.
Collapse
Affiliation(s)
- Julia M Moyett
- Medical Student, Duke University School of Medicine, Durham, NC
| | | | | | - Amy MacDonald
- Director, Group Care, Pomelo Care Affiliation, Bethesda, MD
| | | | | | - Sarah K Dotters-Katz
- Associate Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| |
Collapse
|
4
|
Lazar J, Boned-Rico L, Olander EK, McCourt C. A systematic review of providers' experiences of facilitating group antenatal care. Reprod Health 2021; 18:180. [PMID: 34493314 PMCID: PMC8425020 DOI: 10.1186/s12978-021-01200-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background Group antenatal care is a rapidly expanding alternative antenatal care delivery model. Research has shown it to be a safe and effective care model for women, but less is known about the perspectives of the providers leading this care. This systematic review examined published literature that considered health care professionals’ experiences of facilitating group antenatal care. Methods Systematic searches were conducted in seven databases (Cinahl, Medline, Psychinfo, Embase, Ovid Emcare, Global Health and MIDRS) in April 2020. Qualitative or mixed methods studies with a significant qualitative component were eligible for inclusion if they included a focus on the experiences of health care providers who had facilitated group antenatal care. Prisma screening guidelines were followed and study quality was critically appraised by three independent reviewers. The findings were synthesised thematically. Results Nineteen papers from nine countries were included. Three main themes emerged within provider experiences of group antenatal care. The first theme, ‘Giving women the care providers feel they want and need’, addresses richer use of time, more personal care, more support, and continuity of care. The second theme, ‘Building skills and relationships’, highlights autonomy, role development and hierarchy dissolution. The final theme, ‘Value proposition of group antenatal care’, discusses provider investment and workload. Conclusions Health care providers’ experience of delivering group antenatal care was positive overall. Opportunities to deliver high-quality care that benefits women and allows providers to develop their professional role were appreciated. Questions about the providers’ perspectives on workload, task shifting, and the structural changes needed to support the sustainability of group antenatal care warrant further exploration. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01200-0. Receiving antenatal care in a group setting has been found to be safe and satisfying for women and is supported by international public health guidelines. However, questions remain about the experience of health care professionals tasked with providing this model, such as whether they like working in this model and whether they support its expansion. To answer these questions, the team searched for studies about the experiences of health care providers with group antenatal care, and only included those studies where providers themselves spoke about their own experiences of providing this kind of care. Our review demonstrated that midwives, doctors, nurses and community health workers mostly enjoyed facilitating group antenatal care. They particularly appreciated the ability to give women the kind of care they felt women want and need. Health care providers also experienced some changes in their professional roles, in relation to both the women they serve and their colleagues and organizations. In order to determine if group antenatal care models are a satisfying and sustainable option for health care professionals in the long term, more research is needed.
Collapse
|
5
|
Novick G, Womack JA, Sadler LS. Beyond Implementation: Sustaining Group Prenatal Care and Group Well-Child Care. J Midwifery Womens Health 2020; 65:512-519. [PMID: 32519425 DOI: 10.1111/jmwh.13114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/01/2020] [Accepted: 03/09/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Group prenatal care and group well-child care (collectively called group care) provide health care in groups. Group care is being introduced in many settings, and the model's benefits are increasingly recognized. Yet, little attention has been paid to understanding model sustainability. This study examined barriers to sustainability and offers suggestions for sustaining group care programs. METHODS This qualitative research was guided by interpretive description. Semistructured interviews with 17 professionals were conducted in 4 sites in one community to explore barriers to sustaining group care and key ingredients for sustainability. Sites were 2 clinics that had provided group prenatal care, a clinic currently providing group prenatal care, and a clinic currently providing group well-child care. Two clinics have continued providing group care and 2 have discontinued it. Participants included midwives, physicians, nurses, and nurse practitioners. Interviews were audio recorded, transcribed, and entered in ATLAS.ti. A priori and inductive coding schemes were developed; code content was compared across individuals, participant types, and settings. RESULTS Five themes were identified: administrative buy-in, robust recruitment, clinician and staff buy-in, owning it, and sustainability mindset. Group care needs to be sold to many different constituencies: administrators, staff and clinicians, and patients. Furthermore, sustainability requires having a conscious awareness of the importance of sustainability from the outset, taking ownership by adapting group care to needs of settings, creating venues for expressing divergent viewpoints and problem-solving, and recognizing that these processes are ongoing with change occurring incrementally. It also includes addressing the need for long-term financing. DISCUSSION Those implementing group care must be prepared to go beyond managing the logistics of introducing a complex new program; they must also be prepared to develop sustainability mindsets, sell the model to everyone on all levels within their institutions, and advocate for enhanced reimbursement for group care and value-driven payment systems.
Collapse
Affiliation(s)
- Gina Novick
- Yale University School of Nursing, West Haven, Connecticut
| | - Julie A Womack
- Yale University School of Nursing, West Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lois S Sadler
- Yale University School of Nursing, West Haven, Connecticut.,Yale Child Study Center, New Haven, Connecticut
| |
Collapse
|
6
|
Harsha Bangura A, Nirola I, Thapa P, Citrin D, Belbase B, Bogati B, B K N, Khadka S, Kunwar L, Halliday S, Choudhury N, Schwarz R, Adhikari M, Kalaunee SP, Rising S, Maru D, Maru S. Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health 2020; 17:5. [PMID: 31952543 PMCID: PMC6967133 DOI: 10.1186/s12978-019-0840-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/02/2019] [Indexed: 12/04/2022] Open
Abstract
Background Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. Methods The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. Results A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1–91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. Conclusion Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. Trial registration ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.
Collapse
Affiliation(s)
| | - Isha Nirola
- Harvard T.H, Chan School of Public Health, Boston, MA, USA
| | - Poshan Thapa
- University of New South Wales, School of Public Health and Community Medicine, Sydney, NSW, Australia
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Anthropology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Possible, New York, NY, USA
| | | | - Bhawana Bogati
- Nyaya Health Nepal, Kathmandu, Nepal.,Possible, New York, NY, USA
| | - Nirmala B K
- Om Health Science Campus, Purbanchal University, Kathmandu, VA, Nepal
| | - Sonu Khadka
- Nyaya Health Nepal, Kathmandu, Nepal.,Possible, New York, NY, USA
| | - Lal Kunwar
- Nyaya Health Nepal, Kathmandu, Nepal.,Possible, New York, NY, USA
| | - Scott Halliday
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Global Health, University of Washington, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Possible, New York, NY, USA
| | - Nandini Choudhury
- Nyaya Health Nepal, Kathmandu, Nepal.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Possible, New York, NY, USA
| | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Medicine, Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Division of General Internal Medicine, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Possible, New York, NY, USA
| | | | - S P Kalaunee
- Nyaya Health Nepal, Kathmandu, Nepal.,Eastern University, College of Business and Leadership, St. Davids, PA, USA.,Possible, New York, NY, USA
| | | | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal.,Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA.,Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, New York, NY, USA.,Possible, New York, NY, USA
| | - Sheela Maru
- Nyaya Health Nepal, Kathmandu, Nepal. .,Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, 1216 Fifth Avenue Fifth Floor, Room 556, New York, NY, 10029, USA. .,Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY, USA. .,Possible, New York, NY, USA.
| |
Collapse
|
7
|
Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Provision and uptake of routine antenatal services: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019; 6:CD012392. [PMID: 31194903 PMCID: PMC6564082 DOI: 10.1002/14651858.cd012392.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future. OBJECTIVES To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers. SEARCH METHODS To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase. SELECTION CRITERIA We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education. DATA COLLECTION AND ANALYSIS Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour. MAIN RESULTS We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies. AUTHORS' CONCLUSIONS This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.
Collapse
Affiliation(s)
- Soo Downe
- University of Central LancashireResearch in Childbirth and Health (ReaCH) unitPrestonUKPR1 2HE
| | - Kenneth Finlayson
- University of Central LancashireResearch in Childbirth and Health (ReaCH) unitPrestonUKPR1 2HE
| | - Özge Tunçalp
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | |
Collapse
|
8
|
Cunningham SD, Lewis JB, Shebl FM, Boyd LM, Robinson MA, Grilo SA, Lewis SM, Pruett AL, Ickovics JR. Group Prenatal Care Reduces Risk of Preterm Birth and Low Birth Weight: A Matched Cohort Study. J Womens Health (Larchmt) 2019; 28:17-22. [DOI: 10.1089/jwh.2017.6817] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | | | | | - Lisa M. Boyd
- Yale School of Public Health, New Haven, Connecticut
| | | | | | - Susan M. Lewis
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne L. Pruett
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | |
Collapse
|
9
|
The Impact of Introducing Centering Pregnancy in a Community Health Setting: A Qualitative Study of Experiences and Perspectives of Health Center Clinical and Support Staff. Matern Child Health J 2018; 21:1327-1335. [PMID: 28083727 DOI: 10.1007/s10995-016-2236-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives Introducing new programming into an existing setting may be challenging. Understanding how staff and clinicians who are not directly involved in program delivery view the program can help support program implementation. This study aimed to understand how peripheral staff and clinicians perceived a newly implemented Centering Pregnancy group prenatal care program in a community-based health center and its impact on clinic operations. Methods Semi-structured interviews were conducted with a purposive sample of 12 staff members at a community-based health center. The interview guide covered topics such as perceptions of Centering Pregnancy and how the program impacted their work. An interpretive description approach was used to analyze the interview data. A coding framework was developed iteratively and all interview data were analyzed independently by multiple researchers. Results Staff had overall positive perceptions of Centering Pregnancy, but the level of understanding about the program varied widely. Most respondents viewed the Centering Pregnancy program as separate from other programs offered by the clinic, which created both opportunities and challenges. Opportunities included increased cross-referrals between established services and Centering Pregnancy. Challenges included a lack of communication about responsibilities of staff in relation to Centering Pregnancy patients. Impact on staff and overall clinic operations was perceived to be minimal to moderate, and most tensions related to roles and expectations were resolved. Conclusions for Practice Clear communication regarding fit within clinic structures and processes and expectations of staff in relation to the program was critical to the integration of Centering Pregnancy program into an established health center.
Collapse
|
10
|
Morrell CJ, Sutcliffe P, Booth A, Stevens J, Scope A, Stevenson M, Harvey R, Bessey A, Cantrell A, Dennis CL, Ren S, Ragonesi M, Barkham M, Churchill D, Henshaw C, Newstead J, Slade P, Spiby H, Stewart-Brown S. A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technol Assess 2018; 20:1-414. [PMID: 27184772 DOI: 10.3310/hta20370] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND. OBJECTIVES To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness. DATA SOURCES We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013. REVIEW METHODS Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values. RESULTS From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money. LIMITATIONS In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive. CONCLUSIONS Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. FUTURE WORK RECOMMENDATIONS Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered. STUDY REGISTRATION This study is registered as PROSPERO CRD42012003273. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- C Jane Morrell
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Sutcliffe
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rebecca Harvey
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alice Bessey
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy-Lee Dennis
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Shijie Ren
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Margherita Ragonesi
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Barkham
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Dick Churchill
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Carol Henshaw
- Division of Psychiatry, Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Jo Newstead
- Nottingham Experts Patients Group, Clinical Reference Group for Perinatal Mental Health, Nottingham, UK
| | - Pauline Slade
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Helen Spiby
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Stewart-Brown
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
11
|
Barnes J, Stuart J, Allen E, Petrou S, Sturgess J, Barlow J, Macdonald G, Spiby H, Aistrop D, Melhuish E, Kim S, Pink J, Datta J, Elbourne D. Results of the First Steps study: a randomised controlled trial and economic evaluation of the Group Family Nurse Partnership (gFNP) programme compared with usual care in improving outcomes for high-risk mothers and their children and preventing abuse. PUBLIC HEALTH RESEARCH 2017. [DOI: 10.3310/phr05090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundFamily Nurse Partnership (FNP) is a home-based nurse home-visiting programme to support vulnerable parents. Group Family Nurse Partnership (gFNP) has similar aims and materials and was demonstrated to be feasible in implementation evaluations.ObjectivesTo determine whether or not gFNP, compared with usual care, could reduce risk factors for maltreatment in a vulnerable group and be cost-effective.DesignA multisite randomised controlled parallel-group trial and prospective economic evaluation, with eligible women allocated (minimised by site and maternal age group) to gFNP or usual care.SettingCommunity locations in the UK.ParticipantsExpectant mothers aged < 20 years with one or more previous live births, or expectant mothers aged 20–24 years with no previous live births and with low educational qualifications (defined as General Certificate of Education at grade C or higher in neither mathematics nor English language or, if they had both, no more than four General Certificates of Education at grade C or higher).InterventionForty-four sessions of gFNP (14 during pregnancy and 30 in the first 12 months after birth) were offered to groups of between 8 and 12 women with similar expected delivery dates (the difference between the earliest and latest expected delivery date ranged from 8 to 10 weeks depending on the group) by two family nurses (FNs), one of whom had notified her intention to practise as a midwife.Main outcome measuresParenting was assessed by a self-report measure of parenting opinions, the Adult Adolescent Parenting Inventory Version 2 (AAPI-2), and an objective measure of maternal sensitivity, the CARE-Index. Cost-effectiveness was primarily expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained.Data sourcesInterviews with participants at baseline and when infants were aged 2, 6 and 12 months. Cost information from nurse weekly logs and other service delivery data.ResultsIn total, 166 women were enrolled (99 to the intervention group and 67 to the control group). Adjusting for site and maternal age group, the intention-to-treat analysis found no effect of gFNP on either of the primary outcomes. AAPI-2 total was 7.5/10 [standard error (SE) 0.1] in both arms [difference also adjusted for baseline 0.08, 95% confidence interval (CI) –0.15 to 0.28;p = 0.50]. CARE-Index maternal sensitivity mean: intervention 4.0 (SE 0.3); control 4.7 (SE 0.4) (difference –0.76, 95% CI –1.67 to 0.13;p = 0.21). The sensitivity analyses supported the primary analyses. The probability that the gFNP intervention was cost-effective based on the QALY measure did not exceed 3%. However, in terms ofchangein AAPI-2 score (baseline to 12 months), the probability that gFNP was cost-effective reached 25.1%. A separate discrete choice experiment highlighted the value placed by both pregnant women and members of the general population on non-health outcomes that were not included in the QALY metric.LimitationsSlow recruitment resulted in smaller than ideal group sizes. In some cases, few or no sessions took place owing to low initial group size, and small groups may have contributed to attrition from the intervention. Exposure to gFNP sessions was below maximum for most group members, with only 58 of the 97 intervention participants receiving any sessions; FNs were experienced with FNP but were mainly new to delivering gFNP.ConclusionsThe trial does not support the delivery of gFNP as a means of reducing the risk of child abuse or neglect in this population.Future workA randomised controlled trial with modified eligibility to enable first-time mothers aged < 20 years to be included, and a modified recruitment strategy to enable faster identification of potential participants from antenatal medical records.Trial registrationCurrent Controlled Trials ISRCTN78814904.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 5, No. 9. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Jacqueline Barnes
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Jane Stuart
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Joanna Sturgess
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Jane Barlow
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Helen Spiby
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Dipti Aistrop
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Edward Melhuish
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Sungwook Kim
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Joshua Pink
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jessica Datta
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
12
|
Cunningham SD, Lewis JB, Thomas JL, Grilo SA, Ickovics JR. Expect With Me: development and evaluation design for an innovative model of group prenatal care to improve perinatal outcomes. BMC Pregnancy Childbirth 2017; 17:147. [PMID: 28521785 PMCID: PMC5437650 DOI: 10.1186/s12884-017-1327-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/10/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Despite biomedical advances and intervention efforts, rates of preterm birth and other adverse outcomes in the United States have remained relatively intransigent. Evidence suggests that group prenatal care can reduce these risks, with implications for maternal and child health as well as substantial cost savings. However, widespread dissemination presents challenges, in part because training and health systems have not been designed to deliver care in a group setting. This manuscript describes the design and evaluation of Expect With Me, an innovative model of group prenatal care with a strong integrated information technology (IT) platform designed to be scalable nationally. METHODS/DESIGN Expect With Me follows clinical guidelines from the American Congress of Obstetricians and Gynecologists. Expect With Me incorporates the best evidence-based features of existing models of group care with a novel integrated IT platform designed to improve patient engagement and support, enhance health behaviors and decision making, connect providers and patients, and improve health service delivery. A multisite prospective longitudinal cohort study is being conducted to examine the impact of Expect With Me on perinatal and postpartum outcomes, and to identify and address barriers to national scalability. Process and outcome evaluation will include quantitative and qualitative data collection at patient, provider, and organizational levels. Mixed-method data collection includes patient surveys, medical record reviews, patient focus groups; provider surveys, session evaluations, provider focus groups and in-depth interviews; an online tracking system; and clinical site visits. A two-to-one matched cohort of women receiving individual care from each site will provide a comparison group (n = 1,000 Expect With Me patients; n = 2,000 individual care patients) for outcome and cost analyses. DISCUSSION By bundling prevention and care services into a high-touch, high-tech group prenatal care model, Expect With Me has the potential to result in fundamental changes to the health care system to meet the "triple aim:" better healthcare quality, improved outcomes, and lower costs. Findings from this study will be used to optimize the dissemination and effectiveness of this model. TRIAL REGISTRATION ClinicalTrials.gov, NCT02169024 . Retrospectively registered on June 18, 2014.
Collapse
Affiliation(s)
- Shayna D Cunningham
- Yale School of Public Health, 135 College Street, Room 226, New Haven, CT, 06510, USA.
| | - Jessica B Lewis
- Yale School of Public Health, 135 College Street, Room 226, New Haven, CT, 06510, USA
| | - Jordan L Thomas
- Yale School of Public Health, 135 College Street, Room 226, New Haven, CT, 06510, USA
| | - Stephanie A Grilo
- Yale School of Public Health, 135 College Street, Room 226, New Haven, CT, 06510, USA
| | - Jeannette R Ickovics
- Yale School of Public Health, 135 College Street, Room 226, New Haven, CT, 06510, USA
| |
Collapse
|
13
|
Nisbeth Jensen M, Fage-Butler AM. Antenatal group consultations: Facilitating patient-patient education. PATIENT EDUCATION AND COUNSELING 2016; 99:1999-2004. [PMID: 27497838 DOI: 10.1016/j.pec.2016.07.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/21/2016] [Accepted: 07/29/2016] [Indexed: 05/12/2023]
Abstract
OBJECTIVE This article investigates the perspectives of pregnant women attending antenatal group consultations to gain their understandings of whether and how peer learning is facilitated in this setting. METHODS We conducted semi-structured individual interviews with 16 women who had participated in group consultations at Aarhus University Hospital, Denmark, and analysed the data using qualitative content analysis. Our research design also included observations and patient guest book data. RESULTS Women who were pregnant for the first time greatly appreciated the experiential knowledge of multiparous women in the group. Group consultations provided new learning opportunities, as individuals' questions prompted learning within the groups, as well as questions and answers. There was more time for reflection in group consultations than in dyadic communication. Midwives played a key role in facilitating peer learning. Some topics were not deemed appropriate for discussion. CONCLUSION Antenatal group consultations can support learning, as individuals participate positively both in their own knowledge acquisition and that of others. We call such peer learning patient-patient education. PRACTICE IMPLICATIONS Our study indicates the strengths of group consultations for learning from the perspective of the group members. It highlights how learning may be facilitated in group consultations, and thus has broad practical relevance.
Collapse
Affiliation(s)
- Matilde Nisbeth Jensen
- Department of Business Communication, Jens Chr. Skous Vej 4, Aarhus University, 8000 Aarhus C, Denmark.
| | | |
Collapse
|
14
|
Lathrop B, Pritham UA. A pilot study of prenatal care visits blended group and individual for women with low income. Nurs Womens Health 2016; 18:462-74. [PMID: 25495967 DOI: 10.1111/1751-486x.12159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Healthy Pregnancy, Healthy Childbirth, Healthy Parenting (HPCP) is a blended prenatal care model that integrates group visits with individual prenatal visits. While group prenatal care has been found to have a positive impact on pregnancy outcomes, current models may not be feasible or desirable in all clinical settings. HPCP offers one educational group visit each trimester to improve knowledge of self-care during pregnancy and of childbirth and infant care. The program was piloted among women with low income in a southern metropolitan area. This article presents the findings of a pilot study that examined maternal knowledge acquisition and subsequent changes in self-efficacy and satisfaction with care. Suggestions for future use of a blended model for the delivery of prenatal care are shared.
Collapse
|
15
|
Novick G, Womack JA, Lewis J, Stasko EC, Rising SS, Sadler LS, Cunningham SC, Tobin JN, Ickovics JR. Perceptions of Barriers and Facilitators During Implementation of a Complex Model of Group Prenatal Care in Six Urban Sites. Res Nurs Health 2015; 38:462-74. [PMID: 26340483 DOI: 10.1002/nur.21681] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 11/06/2022]
Abstract
Group prenatal care improves perinatal outcomes, but implementing this complex model places substantial demands on settings designed for individual care. To describe perceived barriers and facilitators to implementing and sustaining CenteringPregnancy Plus (CP+) group prenatal care, 24 in-depth interviews were conducted with 22 clinicians, staff, administrators, and study personnel in six of the 14 sites of a randomized trial of the model. All sites served low-income, minority women. Sites for the present evaluation were selected for variation in location, study arm, and initial implementation response. Implementing CP+ was challenging in all sites, requiring substantial adaptations of clinical systems. All sites had barriers to meeting the model's demands, but how sites responded to these barriers affected whether implementation thrived or struggled. Thriving sites had organizational cultures that supported innovation, champions who advocated for CP+, and staff who viewed logistical demands as manageable hurdles. Struggling sites had bureaucratic organizational structures and lacked buy-in and financial resources, and staff were overwhelmed by the model's challenges. Findings suggested that implementing and sustaining health care innovation requires new practices and different ways of thinking, and health systems may not fully recognize the magnitude of change required. Consequently, evidence-based practices are modified or discontinued, and outcomes may differ from those in the original controlled studies. Before implementing new models of care, clinical settings should anticipate model demands and assess capacity for adapting to the disruptions of innovation.
Collapse
Affiliation(s)
- Gina Novick
- Assistant Professor, School of Nursing, Yale University West Campus, P.O. Box 27399, West Haven, CT, 06516
| | - Julie A Womack
- Assistant Professor, Yale University School of Nursing, VA Connecticut Healthcare System, West Haven, CT
| | - Jessica Lewis
- Research Associate, Yale School of Public Health, New Haven, CT
| | - Emily C Stasko
- Doctoral Student, Department of Psychology, Drexel University, Philadelphia, PA
| | - Sharon S Rising
- Founder and President Emeritus, Centering Healthcare Institute, Silver Spring, MD
| | - Lois S Sadler
- Professor, Yale University School of Nursing, Yale Child Study Center, West Haven, CT
| | | | - Jonathan N Tobin
- President/CEO, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Yeshiva University, Clinical Directors Network, Bronx, NY
| | | |
Collapse
|
16
|
Sawtell M, Jamieson L, Wiggins M, Smith F, Ingold A, Hargreaves K, Khatwa M, Brooks L, Thompson R, Christie D. Implementing a structured education program for children with diabetes: lessons learnt from an integrated process evaluation. BMJ Open Diabetes Res Care 2015; 3:e000065. [PMID: 25969740 PMCID: PMC4419460 DOI: 10.1136/bmjdrc-2014-000065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There is recognition of an urgent need for clinic-based interventions for young people with type 1 diabetes mellitus that improve glycemic control and quality of life. The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured educational group program, using psychological techniques, delivered primarily by diabetes nurses. Composed of four modules, it is designed for children with poor diabetic control and their parents. A mixed methods process evaluation, embedded within a cluster randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived impact of CASCADE. METHODS 28 pediatric diabetes clinics across England participated and 362 children aged 8-16 years, with type 1 diabetes and a mean glycosylated hemoglobin (HbA1c) of 8.5 or above, took part. The process evaluation used a wide range of research methods. RESULTS Of the 180 families in the intervention group, only 55 (30%) received the full program with 53% attending at least one module. Only 68% of possible groups were run. Staff found organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory group composition. Some staff also reported difficulties in mastering the psychological techniques. Uptake, by families, was influenced by the number of groups run and by school, work and other commitments. Attendees described improved: family relationships; knowledge and understanding; confidence; motivation to manage the disease. The results of the trial showed that the intervention did not significantly improve HbA1c at 12 or 24 months. CONCLUSIONS Clinic-based structured group education delivered by staff using psychological techniques had perceived benefits for parents and young people. Staff and families considered it a valuable intervention, yet uptake was poor and the burden on staff was high. Recommendations are made to inform issues related to organization, design, and delivery in order to potentially enhance the impact of CASCADE and future programs. CURRENT CONTROLLED TRIALS ISRCTN52537669.
Collapse
Affiliation(s)
- Mary Sawtell
- Social Science Research Unit, UCL Institute of Education, London, UK
| | - Liz Jamieson
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Meg Wiggins
- Social Science Research Unit, Institute of Education, London, UK
| | - Felicity Smith
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Anne Ingold
- Social Science Research Unit, Institute of Education, London, UK
| | | | - Meena Khatwa
- Social Science Research Unit, Institute of Education, London, UK
| | - Lucy Brooks
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca Thompson
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Deborah Christie
- University College London Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
17
|
Swedish Midwives’ Perspectives of Antenatal Care Focusing on Group-Based Antenatal Care. INTERNATIONAL JOURNAL OF CHILDBIRTH 2014. [DOI: 10.1891/2156-5287.4.4.240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND:Antenatal care in Sweden is routinely delivered on an individual level with optional parental education classes. Group-based antenatal care (GBAC) is a model of antenatal care that has been implemented in Sweden since the year 2000.AIM:Previous research has focused mainly on parents’ experiences and perceptions of GBAC. Midwives have an important role in developing Swedish antenatal care, but studies focusing on midwives’ perspectives are rare. Hence, the aim of this study was to investigate and describe antenatal midwives’ perceptions and experiences of their current work, with a special focus on their opinions about GBAC.METHOD:An interview study was conducted and analyzed by descriptive statistics and quantitative content analysis.PARTICIPANTS:56 midwives from 52 antenatal clinics in Sweden.RESULTS:The major findings of this study were that midwives were satisfied with their work in antenatal care but have reservations concerning time constraints and parental classes. More than half of the midwives reported an interest in trying the group model but expressed personal and organizational obstacles based on identifiable difficulties in implementing the model. Midwives had strong opinions about the suitability of the model for women.CONCLUSION:This is the first study in Sweden to investigate midwives’ perspectives on GBAC. Midwives showed an interest in the group model but have concerns about implementing the process. The midwives considered GBAC as inappropriate for immigrants and well-educated parents.
Collapse
|
18
|
Novick G, Reid AE, Lewis J, Kershaw TS, Rising SS, Ickovics JR. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol 2013; 209:112.e1-6. [PMID: 23524175 DOI: 10.1016/j.ajog.2013.03.026] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/27/2013] [Accepted: 03/19/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE CenteringPregnancy group prenatal care has been demonstrated to improve pregnancy outcomes. However, there is likely variation in how the model is implemented in clinical practice, which may be associated with efficacy, and therefore variation, in outcomes. We examined the association of fidelity to process and content of the CenteringPregnancy group prenatal care model with outcomes previously shown to be affected in a clinical trial: preterm birth, adequacy of prenatal care, and breast-feeding initiation. STUDY DESIGN Participants were 519 women who received CenteringPregnancy group prenatal care. Process fidelity reflected how facilitative leaders were and how involved participants were in each session. Content fidelity reflected whether recommended content was discussed in each session. Fidelity was rated at each session by a trained researcher. Preterm birth and adequacy of care were abstracted from medical records. Participants self-reported breast-feeding initiation at 6 months postpartum. RESULTS Controlling for important clinical predictors, greater process fidelity was associated with significantly lower odds of both preterm birth (B = -0.43, Wald χ(2) = 8.65, P = .001) and intensive utilization of care (B = -0.29, Wald χ(2) = 3.91, P = .05). Greater content fidelity was associated with lower odds of intensive utilization of care (B = -0.03, Wald χ(2) = 9.31, P = .001). CONCLUSION Maintaining fidelity to facilitative group processes in CenteringPregnancy was associated with significant reductions in preterm birth and intensive utilization of care. Content fidelity also was associated with reductions in intensive utilization of care. Clinicians learning to facilitate group care should receive training in facilitative leadership, emphasizing the critical role that creating a participatory atmosphere can play in improving outcomes.
Collapse
Affiliation(s)
- Gina Novick
- School of Nursing, Yale University, New Haven, CT, USA
| | | | | | | | | | | |
Collapse
|
19
|
Novick G, Sadler LS, Knafl KA, Groce NE, Kennedy HP. The intersection of everyday life and group prenatal care for women in two urban clinics. J Health Care Poor Underserved 2012; 23:589-603. [PMID: 22643609 DOI: 10.1353/hpu.2012.0060] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Women from vulnerable populations encounter challenging circumstances that generate stress and may adversely affect their health. Group prenatal care (GPNC) incorporates features that address social stressors, and has been demonstrated to improve pregnancy outcomes and prenatal care experiences. In this qualitative study, we describe the complex circumstances in the lives of women receiving care in two urban clinics and how GPNC attenuated them. Stressors included problems with transportation and child care, demanding jobs, poverty, homelessness, difficult relationships with partners, limited family support, and frustrating health care experiences. Receiving prenatal care in groups allowed women to strengthen relationships with significant others, gain social support, and develop meaningful relationships with group leaders. By eliminating waits and providing the opportunity to participate in care, GPNC also offered sanctuary from frustrations encountered in receiving individual care. Reducing such stressors may help improve pregnancy outcomes; however, more evidence is needed on mechanisms underlying these effects.
Collapse
|