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Soares IADA, Góes FGB, da Silva ACSS, Pereira-Ávila FMV, de Oliveira GB, Silva MDA. Health education website on home care for newborns: construction, validation, and evaluation. Rev Lat Am Enfermagem 2024; 32:e4197. [PMID: 38922266 PMCID: PMC11182603 DOI: 10.1590/1518-8345.7222.4197] [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: 12/08/2023] [Accepted: 02/11/2024] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVE to build, validate, and evaluate an educational health website on home care for newborns for use by pregnant women, postpartum women, and family members. METHOD methodological study developed according to the Analyze, Design, Develop, Implement, and Evaluate model. After construction, the website was validated by 20 experts and evaluated by 20 individuals from the target audience, and the data wasanalyzed according to the Concordance Index with a cut-off point equal to or greater than 0.7 (70%). RESULTS in the validation, the Concordance Index for all the items was higher than 0.7 (70%), with a variation between 0.75 (75%) and 1 (100%), reaching an overall average value of 0.91 (91%). In the evaluation, all the items got top marks, with anoverall average value of 1 (100%). CONCLUSION the educational website was built, validated, and evaluated in a satisfactory manner. It can be considered an appropriate tool for its purpose, with benefits in the teaching-learning process for families regarding postnatal home care fornewborns through its use. It can also be used to educate students and health professionals. The website is available for free access via laptops, computers, smartphones, or tablets.
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Affiliation(s)
- Iasmym Alves de Andrade Soares
- Universidade Federal Fluminense, Instituto de Humanidades e Saúde, Rio das Ostras, RJ, Brazil
- Scholarship holder at the Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Brazil
| | - Fernanda Garcia Bezerra Góes
- Universidade Federal Fluminense, Instituto de Humanidades e Saúde, Rio das Ostras, RJ, Brazil
- Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Wimbarti S, Kairupan BHR, Tallei TE. Critical review of self-diagnosis of mental health conditions using artificial intelligence. Int J Ment Health Nurs 2024; 33:344-358. [PMID: 38345132 DOI: 10.1111/inm.13303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 03/10/2024]
Abstract
The advent of artificial intelligence (AI) has revolutionised various aspects of our lives, including mental health nursing. AI-driven tools and applications have provided a convenient and accessible means for individuals to assess their mental well-being within the confines of their homes. Nonetheless, the widespread trend of self-diagnosing mental health conditions through AI poses considerable risks. This review article examines the perils associated with relying on AI for self-diagnosis in mental health, highlighting the constraints and possible adverse outcomes that can arise from such practices. It delves into the ethical, psychological, and social implications, underscoring the vital role of mental health professionals, including psychologists, psychiatrists, and nursing specialists, in providing professional assistance and guidance. This article aims to highlight the importance of seeking professional assistance and guidance in addressing mental health concerns, especially in the era of AI-driven self-diagnosis.
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Affiliation(s)
- Supra Wimbarti
- Faculty of Psychology, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - B H Ralph Kairupan
- Department of Psychiatry, Faculty of Medicine, Sam Ratulangi University, Manado, North Sulawesi, Indonesia
| | - Trina Ekawati Tallei
- Department of Biology, Faculty of Mathematics and Natural Sciences, Sam Ratulangi University, Manado, North Sulawesi, Indonesia
- Department of Biology, Faculty of Medicine, Sam Ratulangi University, Manado, North Sulawesi, Indonesia
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Van Haeken S, Braeken MAKA, Groenen A, Bogaerts A. A Supported Online Resilience-Enhancing Intervention for Pregnant Women: A Non-Randomized Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:209. [PMID: 38397698 PMCID: PMC10887965 DOI: 10.3390/ijerph21020209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024]
Abstract
A 28-week supported online intervention for pregnant women, informed by the Behavior Change Wheel Framework, was developed. The intervention included exercises, group sessions and a peer support platform. The aim of this study was to examine the potential effectiveness of the intervention in enhancing resilience and promoting maternal mental health. Using a quasi-experimental design, assessments were conducted at baseline, postintervention and follow-ups at six and 12 months after childbirth. Resilience, resilience attributes, and maternal mental health were measured using standardised scales. The intervention group received the intervention (N = 70), while the control group (N = 32) received care-as-usual. A repeated-measures ANOVA was used to determine within- and between-group changes. Results showed no significant differences between groups regarding resilience and maternal mental health. However, the intervention group demonstrated stable resilience (p = 0.320) compared to a significant decrease in the control group (p = 0.004). Within the intervention group, perceived social support remained stable during the intervention, but decreased significantly at the first follow-up (p = 0.012). All participants faced additional stress from the COVID-19 pandemic alongside the challenges of parenthood. This study contributes to maternal mental health literature with an innovative, supported online intervention. The intervention consists of different deployable components, designed to be offered online, and the current pilot data are promising. Further research is warranted to explore its full potential in clinical practice.
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Affiliation(s)
- Sarah Van Haeken
- Research & Expertise, Expertise Centre Resilient People, University Colleges Leuven-Limburg (UCLL), 3590 Diepenbeek, Belgium;
- REALIFE Research Group, Faculty of Medicine, Department of Development & Regeneration, Women & Child KU Leuven, 3000 Leuven, Belgium;
| | | | - Anne Groenen
- Research & Expertise, Expertise Centre Resilient People, University Colleges Leuven-Limburg (UCLL), 3590 Diepenbeek, Belgium;
- Leuven Institute of Criminology (LINC), Katholieke Universiteit Leuven (KU Leuven), 3000 Leuven, Belgium
| | - Annick Bogaerts
- REALIFE Research Group, Faculty of Medicine, Department of Development & Regeneration, Women & Child KU Leuven, 3000 Leuven, Belgium;
- Faculty of Health, University of Plymouth, Devon PL4 8AA, UK
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Clark JA, Smith LK, Armstrong N. Midwives' and obstetricians' practice, perspectives and experiences in relation to altered fetal movement: A focused ethnographic study. Int J Nurs Stud 2024; 150:104643. [PMID: 38043485 DOI: 10.1016/j.ijnurstu.2023.104643] [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: 01/16/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Reducing avoidable stillbirth is a global priority. The stillbirth rate in England compares unfavourably to that of some other high-income countries. Poorly-managed episodes of altered fetal movement have been highlighted as a key contributor to avoidable stillbirth, and strategies introduced in England in 2016 to reduce perinatal mortality included recommendations for the management of reduced fetal movement. Despite a downward trend in stillbirth rates across the UK, the effects of policies promoting awareness of fetal movement remain uncertain. OBJECTIVE To provide in-depth knowledge of how practice and clinical guidance relating to altered fetal movement are perceived, enacted and experienced by midwives and obstetricians, and explore the relationship between recommended fetal movement care and actual fetal movement care. DESIGN A focused ethnographic approach comprising over 180 h of observation, 15 interviews, and document analysis was used to explore practice at two contrasting UK maternity units. SETTINGS Antenatal services at two UK maternity units, one in the Midlands and one in the North of England. PARTICIPANTS Thirty-six midwives, obstetricians and sonographers and 40 pregnant women participated in the study across 52 observed care episodes and relevant unit activity. Twelve midwives and three obstetricians additionally participated in formal semi-structured interviews. METHODS Fieldnotes, interview transcripts, policy documents, maternity notes and clinical guidelines were analysed using a modified constant comparison method to identify important themes. RESULTS fetal movement practice was mostly consistent and in line with guideline recommendations. Notwithstanding, most midwives and obstetricians had concerns about this area of care, including challenges in diagnosis, conflicting evidence about activity, heightened maternal anxiety, and high rates of monitoring and intervention in otherwise low-risk pregnancies. To address these issues, midwives spent considerable time reassuring women through information and regular monitoring, and coaching them to perceive fetal movement more accurately. CONCLUSIONS Practice relating to altered fetal movement might be more uniform than in the past. However, a heightened focus on fetal movement is associated by some midwives and obstetricians with potential harms, including increased anxiety in pregnancy, and high rates of monitoring and intervention in pregnancies where there are no 'objective concerns'. Challenges in diagnosing a significant change in fetal movement with accuracy might mean that interventions and resources are not being directed towards those pregnancies most at risk. More research is needed to determine how healthcare professionals can engage in conversations about fetal movement and stillbirth to support safe outcomes and positive experiences in pregnancy and birth. REGISTRATION Not registered. TWEETABLE ABSTRACT Midwives and obstetricians take #reducedfetalmovement seriously but worry this 'unreliable' symptom increases anxiety, monitoring and intervention in many 'low risk' pregnancies.
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Affiliation(s)
- Julia A Clark
- Department of Population Health Sciences, University of Leicester, Leicester, UK; School of Health Science, The University of Nottingham, Nottingham, UK.
| | - Lucy K Smith
- Department of Population Health Sciences, University of Leicester, Leicester, UK.
| | - Natalie Armstrong
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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Knowles H, Swoboda TK, Sandlin D, Huggins C, Takami T, Johnson G, Wang H. The association between electronic health information usage and patient-centered communication: a cross sectional analysis from the Health Information National Trends Survey (HINTS). BMC Health Serv Res 2023; 23:1398. [PMID: 38087311 PMCID: PMC10717115 DOI: 10.1186/s12913-023-10426-6] [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: 07/19/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Patient-provider communication can be assessed by the patient-centered communication (PCC) score. With rapid development of electronic health (eHealth) information usage, we are uncertain of their role in PCC. Our study aims to determine the association between PCC and eHealth usage with the analysis of national representative survey data. METHODS This is a cross sectional analysis using the Health Information National Trends Survey 5 (HINTS 5) cycle 1 to cycle 4 data (2017-2020). Seven specific questions were used for PCC assessment, and eHealth usage was divided into two types (private-eHealth and public-eHealth usage). A multivariate logistic regression was performed to determine the association between PCC and eHealth usage after the adjustment of other social, demographic, and clinical variables. RESULTS Our study analyzed a total of 13,055 unweighted participants representing a weighted population of 791,877,728. Approximately 43% of individuals used private eHealth and 19% used public eHealth. The adjusted odds ratio (AOR) of private-eHealth usage associated with positive PCC was 1.17 (95% CI 1.02-1.35, p = 0.027). The AOR of public-eHealth usage associated with positive PCC was 0.84 (95% CI 0.71-0.99, p = 0.043). CONCLUSION Our study found that eHealth usage association with PCC varies. Private-eHealth usage was positively associated with PCC, whereas public-eHealth usage was negatively associated with PCC.
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Affiliation(s)
- Heidi Knowles
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Thomas K Swoboda
- Department of Emergency Medicine, The Valley Health System, Touro University Nevada School of Osteopathic Medicine, 657 N. Town Center Drive, Las Vegas, NV, 89144, USA
| | - Devin Sandlin
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Charles Huggins
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Trevor Takami
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Garrett Johnson
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Hao Wang
- Department of Emergency Medicine, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA.
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Hussain IM, Hartney N, Sweet L. A survey of Australian women's digital media usage in pregnancy and labour and birth. BMC Pregnancy Childbirth 2023; 23:688. [PMID: 37741990 PMCID: PMC10517456 DOI: 10.1186/s12884-023-06003-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Given the rapid growth of digital media resources, it is worth exploring childbearing women's use of digital media to address their information needs. The aim of this study was to explore the use of digital media during pregnancy and birth in the local population of Western Victorian women in Melbourne, Australia. METHODS A descriptive exploratory approach was used. An online survey consisted of both quantitative and qualitative questions to identify and measure digital media use in pregnancy and the birthing period. Descriptive statistics and Pearson Chi-square test were used to analyse the quantitative data, while content analysis was used to analyse the qualitative data. RESULTS Digital media has become an integral part of the experience in pregnancy with increasing growth of digital media in labour. The most used medium for digital media use was pregnancy applications, followed by websites, social media, YouTube, podcasts, online discussion forums and lastly, labour applications. Information seeking was the main reason for using digital media, and two main themes emerged from the qualitative data; 'connection with others for social support and reassurance' and 'information seeking and providing to assist decision making and providing reassurance'. CONCLUSION This study highlights the need for future midwifery practice to include digital media sources in antenatal education and care. There is a need for healthcare institutions to improve digital media technology to meet the needs of women. This is crucial as digital media is constantly evolving, and as healthcare providers, we need to integrate digital media with healthcare services.
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Affiliation(s)
- Ilyana Mohamed Hussain
- School of Nursing and Midwifery, Deakin University, Victoria, Australia
- Western Health, Victoria, Australia
| | - Nicki Hartney
- School of Nursing and Midwifery, Deakin University, Victoria, Australia
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University, Victoria, Australia.
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Western Health Partnership, 221 Burwood Highway, Burwood, VIC, 3125, Australia.
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Morse H, Brown A. UK midwives' perceptions and experiences of using Facebook to provide perinatal support: Results of an exploratory online survey. PLOS DIGITAL HEALTH 2023; 2:e0000043. [PMID: 37068068 PMCID: PMC10109466 DOI: 10.1371/journal.pdig.0000043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 02/01/2023] [Indexed: 04/18/2023]
Abstract
Seeking support from Facebook groups during pregnancy is now widespread and social media has been widely used by the United Kingdom National Health Service (NHS) maternity services to communicate with service users during the COVID-19 pandemic. Despite this, little is currently known about midwives' attitudes towards, and experiences of social media in practice. Research is needed to understand barriers and solutions to meeting mothers' expectations of online support and to improve services. This study explored midwife involvement in Facebook groups, exploring experiences and perceptions of its use to communicate with and support mothers. An online survey consisting of open and closed questions was completed by 719 midwives and student during August- September 2020. Quantitative questionnaire data was analysed descriptively using SPSS v26. Qualitative data gathered from free text responses was analysed using reflexive thematic analysis. Few participants were involved in providing Facebook support, and most of these were unpaid. There was a consensus on a range of benefits for mothers, but widespread concern that engaging with mothers online was a personal and professional risk, underpinned by a lack of support. Experience of being involved in midwife moderation increased belief in its benefits and reduced fear of engaging online, despite a lack of renumeration and resources. Midwives and students felt they were discouraged from offering Facebook support and sought further training, guidance and support. Although limited, experiences of providing Facebook group support are positive. Perceptions of risk and a lack of support are significant barriers to midwives' involvement in using Facebook groups to support mothers. Midwives seek support and training to safely and effectively engage with mothers using Facebook. Engaging with mothers via social media is embedded in UK national policy and NHS digital strategy, and progress is needed to fulfil these, to improve services and meet mothers' expectations. Midwives' experiences suggest extending opportunities to provide Facebook support would benefit midwives, services and families. Consultation to revise local policy to support midwives and students in line with strategic goals is recommended.
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Affiliation(s)
- Holly Morse
- Department of Public Health, Policy and Social Sciences, Swansea University, Wales, United Kingdom
- Centre for Lactation, Infant Feeding and Translation research (LIFT), Swansea University, Wales, United Kingdom
| | - Amy Brown
- Department of Public Health, Policy and Social Sciences, Swansea University, Wales, United Kingdom
- Centre for Lactation, Infant Feeding and Translation research (LIFT), Swansea University, Wales, United Kingdom
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Shah AB, Oyegun E, Hampton WB, Neri A, Maddox N, Raso D, Sandhu P, Patel A, Koonin LM, Lee L, Roper L, Whitfield G, Siegel DA, Koumans EH. Engagement With the Centers for Disease Control and Prevention Coronavirus Self-Checker and Guidance Provided to Users in the United States From March 23, 2020, to April 19, 2021: Thematic and Trend Analysis. J Med Internet Res 2023; 25:e39054. [PMID: 36745776 PMCID: PMC10039408 DOI: 10.2196/39054] [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: 05/04/2022] [Revised: 10/05/2022] [Accepted: 12/22/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In 2020, at the onset of the COVID-19 pandemic, the United States experienced surges in healthcare needs, which challenged capacity throughout the healthcare system. Stay-at-home orders in many jurisdictions, cancellation of elective procedures, and closures of outpatient medical offices disrupted patient access to care. To inform symptomatic persons about when to seek care and potentially help alleviate the burden on the healthcare system, Centers for Disease Control and Prevention (CDC) and partners developed the CDC Coronavirus Self-Checker ("Self-Checker"). This interactive tool assists individuals seeking information about COVID-19 to determine the appropriate level of care by asking demographic, clinical, and nonclinical questions during an online "conversation." OBJECTIVE This paper describes user characteristics, trends in use, and recommendations delivered by the Self-Checker between March 23, 2020, and April 19, 2021, for pursuing appropriate levels of medical care depending on the severity of user symptoms. METHODS User characteristics and trends in completed conversations that resulted in a care message were analyzed. Care messages delivered by the Self-Checker were manually classified into three overarching conversation themes: (1) seek care immediately; (2) take no action, or stay home and self-monitor; and (3) conversation redirected. Trends in 7-day averages of conversations and COVID-19 cases were examined with development and marketing milestones that potentially impacted Self-Checker user engagement. RESULTS Among 16,718,667 completed conversations, the Self-Checker delivered recommendations for 69.27% (n=11,580,738) of all conversations to "take no action, or stay home and self-monitor"; 28.8% (n=4,822,138) of conversations to "seek care immediately"; and 1.89% (n=315,791) of conversations were redirected to other resources without providing any care advice. Among 6.8 million conversations initiated for self-reported sick individuals without life-threatening symptoms, 59.21% resulted in a recommendation to "take no action, or stay home and self-monitor." Nearly all individuals (99.8%) who were not sick were also advised to "take no action, or stay home and self-monitor." CONCLUSIONS The majority of Self-Checker conversations resulted in advice to take no action, or stay home and self-monitor. This guidance may have reduced patient volume on the medical system; however, future studies evaluating patients' satisfaction, intention to follow the care advice received, course of action, and care modality pursued could clarify the impact of the Self-Checker and similar tools during future public health emergencies.
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Affiliation(s)
- Ami B Shah
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
- General Dynamics Information Technology, Falls Church, VA, United States
| | - Eghosa Oyegun
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - William Brett Hampton
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
- General Dynamics Information Technology, Falls Church, VA, United States
| | - Antonio Neri
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - Nicole Maddox
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
- Abt Associates, Rockville, MD, United States
| | - Danielle Raso
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
- General Dynamics Information Technology, Falls Church, VA, United States
| | - Paramjit Sandhu
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - Anita Patel
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - Lisa M Koonin
- Health Preparedness Partners, Atlanta, GA, United States
| | - Leslie Lee
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - Lauren Roper
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - Geoffrey Whitfield
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - David A Siegel
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
| | - Emily H Koumans
- Centers for Disease Control and Prevention, COVID-19 Emergency Response, Atlanta, GA, United States
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Ortega-García JA, Sánchez-Sauco MF, Zafra-Rodríguez JA, Cabrera-Rivera LT, Díaz-Martínez F, Llegus-Santiago EM, Delgado-Marín JL, Orenes-Piñero E, Kloosterman N, Bach A, Ojeda-Sánchez C, Ramis R. Subjective well-being, happiness, and environmental health factors related to women planning a pregnancy or pregnant, using mobile health intervention. Digit Health 2023; 9:20552076231177146. [PMID: 37284011 PMCID: PMC10240876 DOI: 10.1177/20552076231177146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/04/2023] [Indexed: 06/08/2023] Open
Abstract
Objectives To compare the environmental health results in women trying to get pregnant or pregnant using a mobile health application (Green Page) through healthcare professionals or self-completed by women, and to explore the relationship between the subjective well-being of these women with their lifestyles and environmental factors. Methods A descriptive study with mixed methods was conducted in 2018. A mobile health survey was used in two phases. Phase 1 was a cross-sectional study through professionals (n = 1100) followed by phase 2, a convenience sampling through women's self-reporting (n = 3425). A personalized report was downloadable with health recommendations for the well-being of the mother and child. Results Of the 3205 participants (mean age = 33 years, SD = 0.2 years), 1840 were planning a pregnancy and 1365 were pregnant. One in five pregnant women had a low level of happiness. Globally, subjective well-being and happiness were found to be negatively associated with lack of contact with nature, sedentary lifestyle, excess weight, environmental exposure, and older age in pregnancy. Precisely 45%, 60%, and 14% of women were exposed to tobacco, alcohol, and illegal drugs, respectively. The women self-reported levels of risk factors higher than when the tool was used by or through professionals. Conclusions The use of mobile health interventions focused on environmental health during planning or pregnancy periods could help improve the quality of healthcare and foster greater involvement of women in their self-care process, thus promoting empowerment, healthier environments, and lifestyles. Ensuring equity of access and data protection are global challenges to be addressed.
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Affiliation(s)
- Juan Antonio Ortega-García
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Pediatric Environmental Health Speciality Unit (PEHSU), Department of Pediatrics, Clinical University Hospital Virgen of Arrixaca, El Palmar, Murcia, Spain
| | - Miguel Felipe Sánchez-Sauco
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Pediatric Environmental Health Speciality Unit (PEHSU), Department of Pediatrics, Clinical University Hospital Virgen of Arrixaca, El Palmar, Murcia, Spain
| | - José Alberto Zafra-Rodríguez
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- TICARUM, University of Murcia, Murcia, Spain
| | - Laura Teresa Cabrera-Rivera
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Department of Environmental Health, University of Puerto Rico-Medical Sciences Campus, San Juan, Puerto Rico
- International Exchange Program for Minority Student, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Francisco Díaz-Martínez
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Pediatric Environmental Health Speciality Unit (PEHSU), Department of Pediatrics, Clinical University Hospital Virgen of Arrixaca, El Palmar, Murcia, Spain
| | - Eduardo Manuel Llegus-Santiago
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Department of Environmental Health, University of Puerto Rico-Medical Sciences Campus, San Juan, Puerto Rico
- International Exchange Program for Minority Student, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Juan Luis Delgado-Marín
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario Virgen Arrixaca, Fetal Medicine Unit Murcia, IMIB Arrixaca, Región de Murcia, Spain
| | - Esteban Orenes-Piñero
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Departament of Biochemistry and Molecular Biology, University of Murcia, Murcia, Spain
| | - Nicole Kloosterman
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- MUSC Health University Medical Center, Charleston, SC, USA
| | - Albert Bach
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Environment and Human Health Laboratory (EH2 Lab), Forest Science and Technology Center of Catalonia, Solsona, Spain
| | - Carlos Ojeda-Sánchez
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Department of Preventive Medicine, Hospital General Universitario de Guadalajara, Guadalajara, Spain
| | - Rebecca Ramis
- Department of Pediatrics, Global Alliance to Renaturalize Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, IMIB Arrixaca, University of Murcia, Murcia, Spain
- Cancer and Environmental Epidemiology Unit, National Epidemiology Centre, Carlos III Health Institute and Centre for Biomedical Research in Epidemiology & Public Health (CIBER Epidemiología y Salud Pública−CIBERESP), Madrid, Spain
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Gong Q, Bharj K. A qualitative study of the utilisation of digital resources in pregnant Chinese migrant women's maternity care in northern England. Midwifery 2022; 115:103493. [DOI: 10.1016/j.midw.2022.103493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 06/15/2022] [Accepted: 09/23/2022] [Indexed: 10/14/2022]
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Bailey E, Nightingale S, Thomas N, Coleby D, Deave T, Goodenough T, Ginja S, Lingam R, Kendall S, Day C, Coad J. First-time Mothers' Understanding and Use of a Pregnancy and Parenting Mobile App (The Baby Buddy App): Qualitative Study Using Appreciative Inquiry. JMIR Mhealth Uhealth 2022; 10:e32757. [PMID: 36409530 PMCID: PMC9723971 DOI: 10.2196/32757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/17/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Internationally, there is increasing emphasis on early support for pregnant women to optimize the health and development of mothers and newborns. To increase intervention reach, digital and app-based interventions have been advocated. There are growing numbers of pregnancy health care apps with great variation in style, function, and objectives, but evidence about impact on pregnancy well-being and behavior change following app interaction is lacking. This paper reports on the qualitative arm of the independent multicomponent study exploring the use and outcomes of first-time mothers using the Baby Buddy app, a pregnancy and parenting support app, available in the National Health Service App Library and developed by a UK child health and well-being charity, Best Beginnings. OBJECTIVE This study aims to understand when, why, and how first-time mothers use the Baby Buddy app and the perceived benefits and challenges. METHODS This paper reports on the qualitative arm of an independent, longitudinal, mixed methods study. An Appreciative Inquiry qualitative approach was used with semistructured interviews (17/60, 28%) conducted with new mothers, either by telephone or in a focus group setting. First-time mothers were recruited from 3 study sites from across the United Kingdom. Consistent with the Appreciative Inquiry approach, mothers were prompted to discuss what worked well and what could have been better regarding their interactions with the app during pregnancy. Thematic analysis was used, and findings are presented as themes with perceived benefits and challenges. RESULTS The main benefit, or what worked well, for first-time mothers when using the app was being able to access new information, which they felt was reliable and easy to find. This led to a feeling of increased confidence in the information they accessed, thus supporting family and professional communication. The main challenge was the preference for face-to-face information with a health care professional, particularly around specific issues that they wished to discuss in depth. What could have been improved included that there were some topics that some mothers would have preferred in more detail, but in other areas, they felt well-informed and thus did not feel a need to seek additional information via an app. CONCLUSIONS Although this study included a small sample, it elicited rich data and insights into first-time mothers' app interactions. The findings suggest that easily accessible pregnancy information, which is perceived as reliable, can support first-time mothers in communicating with health care professionals. Face-to-face contact with professionals was preferred, particularly to discuss specific and personalized needs. Further studies on maternal and professional digital support preferences after the COVID-19 global pandemic and how they facilitate antenatal education and informed decision-making are recommended, particularly because digital solutions remain as a key element in pregnancy and early parenting care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1017/S1463423618000294.
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Affiliation(s)
- Elizabeth Bailey
- Coventry University, Coventry, United Kingdom
- Elizabeth Bryan Multiple Births Centre, Centre for Social Care, Health and Related Research, Birmingham City University, Birmingham, United Kingdom
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | | | - Nicky Thomas
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Dawn Coleby
- School of Nursing and Midwifery, Faculty of Health and Life Sciences, De Montfort University, Leicester, United Kingdom
| | - Toity Deave
- School of Health and Social Wellbeing, University of the West of England, Bristol, United Kingdom
| | - Trudy Goodenough
- School of Health and Social Wellbeing, University of the West of England, Bristol, United Kingdom
| | - Samuel Ginja
- School of Psychology, Ulster University, Ulster, United Kingdom
| | - Raghu Lingam
- University of New South Wales, Sydney, Australia
| | - Sally Kendall
- Centre for Health Services Studies, University of Kent, Canterbury, United Kingdom
| | - Crispin Day
- Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, United Kingdom
| | - Jane Coad
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- School of Health Sciences, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom
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Novick AM, Kwitowski M, Dempsey J, Cooke DL, Dempsey AG. Technology-Based Approaches for Supporting Perinatal Mental Health. Curr Psychiatry Rep 2022; 24:419-429. [PMID: 35870062 PMCID: PMC9307714 DOI: 10.1007/s11920-022-01349-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE OF REVIEW This review explores advances in the utilization of technology to address perinatal mood and anxiety disorders (PMADs). Specifically, we sought to assess the range of technologies available, their application to PMADs, and evidence supporting use. RECENT FINDINGS We identified a variety of technologies with promising capacity for direct intervention, prevention, and augmentation of clinical care for PMADs. These included wearable technology, electronic consultation, virtual and augmented reality, internet-based cognitive behavioral therapy, and predictive analytics using machine learning. Available evidence for these technologies in PMADs was almost uniformly positive. However, evidence for use in PMADs was limited compared to that in general mental health populations. Proper attention to PMADs has been severely limited by issues of accessibility, affordability, and patient acceptance. Increased use of technology has the potential to address all three of these barriers by facilitating modes of communication, data collection, and patient experience.
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Affiliation(s)
- Andrew M Novick
- Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Ct, MS F546, Aurora, CO, 80045, USA
| | - Melissa Kwitowski
- Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Ct, MS F546, Aurora, CO, 80045, USA
| | - Jack Dempsey
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Danielle L Cooke
- Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Ct, MS F546, Aurora, CO, 80045, USA
| | - Allison G Dempsey
- Department of Psychiatry, University of Colorado School of Medicine, 1890 N Revere Ct, MS F546, Aurora, CO, 80045, USA.
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Patient initiated follow up in Obstetrics and Gynaecology: A systematic review. Eur J Obstet Gynecol Reprod Biol 2022; 272:123-129. [PMID: 35303674 DOI: 10.1016/j.ejogrb.2022.02.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/19/2022] [Accepted: 02/26/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The demand for outpatient hospital appointments has risen steadily over recent years, almost doubling since 2008; now standing at 120 million appointments per year. Initiatives to reduce unnecessary appointments are a key area of interest, as they can be an effective way of both improving patient care and satisfaction, as well as reducing NHS costs. Patient Initiated Follow-Up (PIFU) provides an alternative to traditional hospital instigated follow-up, by which patients have autonomy in their future care, allowing them to make appointments based on their own perception of need. PIFU has proved successful when implemented in Rheumatology, Inflammatory Bowel Disease and Oncology, with trends towards reduced burden on outpatient appointments, improved patient satisfaction and lower costs. To-date, the use of PIFU in women's health has been limited to gynaecological oncology, where observations include high patient satisfaction and fewer appointments than traditional follow-up. This study aims to undertake a systematic review of the literature relating to PIFU in Obstetrics and Gynaecology in order to identify evidence-based indications for PIFU in the specialty, as well as form a foundation for a subsequent service evaluation. METHODS The project was registered with Prospero, University of York. Using the OVID platform, a literature search was conducted using the terms "patient initiated follow up", "gynaecology", "women's health", and "follow up care". Papers were then screened in accordance with the PRISMA protocol, and relevant articles identified based on our inclusion criteria. The quality of the studies was assessed using the Newcastle-Ottawa Scale, and data from the studies were extracted and compared. RESULTS Eight papers were identified as relevant, two were randomised controlled trials, three were retrospective cohort studies, and the remaining three were prospective cohort studies. The majority of these studies (5/8) were of good quality, scoring 6 or more points on the Newcastle-Ottawa Scale. Four of the eight studies examined cost-effectives; all reported cost-savings relating to PIFU. Seven of the eight studies also reported an association between PIFU and greater patient satisfaction, fewer overall appointments and reduced non-attendance. One study reported no effect on patient satisfaction. Five studies related to gynaecological oncology, two were obstetric and one urogynaecology. The studies which investigated PIFU use in selected gynaecological oncology patients reported that PIFU did not have a negative impact on detection of cancer recurrence, but evidence regarding the psychological impact of PIFU on cancer survivors was conflicting. CONCLUSION PIFU was received largely positively and was well accepted by women across these studies. It was also shown to be cost-effective, without a negative impact on health outcomes. PIFU also has the potential to offer additional benefits including reducing diagnostic delay and increasing patient engagement with their own health status. This review found a paucity of data for PIFU in Obstetrics and Gynaecology, with the exception of gynaecological oncology, and further evaluation is required before more widespread implementation.
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Lanssens D, Thijs IM, Dreesen P, Van Hecke A, Coorevits P, Gaethofs G, Derycke J, Tency I. INFORMATION RESOURCES AMONG FLEMISH PREGNANT WOMEN: A CROSS-SECTIONAL STUDY (Preprint). JMIR Form Res 2022; 6:e37866. [PMID: 36222794 PMCID: PMC9597425 DOI: 10.2196/37866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/01/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background There has been an exponential growth in the availability of apps, resulting in increased use of pregnancy apps. However, information on resources and use of apps among pregnant women is relatively limited. Objective The aim of this study is to map the current information resources and the use of pregnancy apps among pregnant women in Flanders. Methods A cross-sectional study was conducted, using a semistructured survey (April-June 2019) consisting of four different domains: (1) demographics; (2) use of devices; (3) sources of information; and (4) use of pregnancy apps. Women were recruited by social media, flyers, and paper questionnaires at prenatal consultations. Statistical analysis was mainly focused on descriptive statistics. Differences in continuous and categorical variables were tested using independent Student t tests and chi-square tests. Correlations were investigated between maternal characteristics and the women’s responses. Results In total, 311 women completed the entire questionnaire. Obstetricians were the primary source of information (268/311, 86.2%) for pregnant women, followed by websites/internet (267/311, 85.9%) and apps (233/311, 74.9%). The information that was most searched for was information about the development of the baby (275/311, 88.5%), discomfort/complaints (251/311, 80.7%) and health during pregnancy (248/311, 79.7%), administrative/practical issues (233/311, 74.9%), and breastfeeding (176/311, 56.6%). About half of the women (172/311, 55.3%) downloaded a pregnancy app, and primarily searched app stores (133/311, 43.0%). Pregnant women who are single asked their mothers (22/30, 73.3%) or other family members (13/30, 43.3%) for significantly more information than did married women (mother [in law]: 82/160, 51.3%, P=.02; family members: 35/160, 21.9%, P=.01). Pregnant women with lower education were significantly more likely to have a PC or laptop than those with higher education (72/73, 98.6% vs 203/237, 85.5%; P=.008), and to consult other family members for pregnancy information (30/73, 41.1% vs 55/237, 23.1%; P<.001), but were less likely to consult a gynecologist (70/73, 95.9% vs 198/237, 83.5%; P=.001). They also followed more prenatal sessions (59/73, 80.8% vs 77/237, 32.5%; P=.04) and were more likely to search for information regarding discomfort/complaints during pregnancy (65/73, 89% vs 188/237, 79.5%; P=.02). Compared to multigravida, primigravida were more likely to solicit advice about their pregnancy from other women in their social networks (family members: primigravida 44/109, 40.4% vs multigravida 40/199, 20.1%; P<.001; other pregnant women: primigravida 58/109, 53.2% vs multigravida 80/199, 40.2%; P<.03). Conclusions Health care professionals need to be aware that apps are important and are a growing source of information for pregnant women. Concerns rise about the quality and safety of those apps, as only a limited number of apps are subjected to an external quality check. Therefore, it is important that health care providers refer to high-quality digital resources and take the opportunity to discuss digital information with pregnant women.
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Affiliation(s)
- Dorien Lanssens
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, University of Hasselt, Hasselt, Belgium
| | - Inge M Thijs
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, University of Hasselt, Hasselt, Belgium
- Obstetric Department and Future Health, Limburg Clinical Research Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pauline Dreesen
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, University of Hasselt, Hasselt, Belgium
- Obstetric Department and Future Health, Limburg Clinical Research Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ann Van Hecke
- Department Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Nursing Department, Ghent University Hospital, Gent, Belgium
| | - Pascal Coorevits
- Department Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Gitte Gaethofs
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, University of Hasselt, Hasselt, Belgium
- Obstetric Department and Future Health, Limburg Clinical Research Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joyce Derycke
- Department Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Inge Tency
- Department Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Department of Midwifery, Odisee University of Applied Sciences, Sint Niklaas, Belgium
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Barber CC, Masters-Awatere B. Positively Pregnant: Development and piloting of a mobile app for social and emotional well-being in pregnancy. Appl Psychol Health Well Being 2021; 14:1255-1272. [PMID: 34959260 DOI: 10.1111/aphw.12333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/12/2021] [Indexed: 11/27/2022]
Abstract
This paper describes development of a mobile e-health application, Positively Pregnant, which provides tools to meet the psychological challenges of pregnancy and transition to parenthood. Positively Pregnant was developed with input from maternity carers and consumers, incorporating local cultures and contexts as well as international research on effective interventions for stress management and mental well-being. The prototype app was piloted with 88 New Zealand women. Participants in the pilot used an average of 11.96 (SD = 7.44) components, and most were satisfied (45.1%) or neutral (40.3%) regarding the app. For 23 of the 26 interactive components, the majority of those who tried the component reported that they found it helpful. Participants reported a significant reduction in subjective stress (η2 = .088, p = .023). Feedback from pilot participants was incorporated in a version of the app that was publically launched as a free tool to support developing families. Mobile e-health applications are a promising medium for providing preventative interventions and psychoeducation about the social and emotional challenges of pregnancy and early parenting; Positively Pregnant is an example of a tool, grounded in strength-based, empirically supported strategies, to provide parents with support and information at this critical time.
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Stacey T, Haith-Cooper M, Almas N, Kenyon C. An exploration of migrant women's perceptions of public health messages to reduce stillbirth in the UK: a qualitative study. BMC Pregnancy Childbirth 2021; 21:394. [PMID: 34016084 PMCID: PMC8136107 DOI: 10.1186/s12884-021-03879-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stillbirth is a global public health priority. Within the United Kingdom, perinatal mortality disproportionately impacts Black, Asian and minority ethnic women, and in particular migrant women. Although the explanation for this remains unclear, it is thought to be multidimensional. Improving perinatal mortality is reliant upon raising awareness of stillbirth and its associated risk factors, as well as improving maternity services. The aim of this study was to explore migrant women's awareness of health messages to reduce stillbirth risk, and how key public health messages can be made more accessible. METHOD Two semi-structured focus groups and 13 one to one interviews were completed with a purposive sample of 30 migrant women from 18 countries and across 4 NHS Trusts. RESULTS Participants provided an account of their general awareness of stillbirth and recollection of the advice they had been given to reduce the risk of stillbirth both before and during pregnancy. They also suggested approaches to how key messages might be more effectively communicated to migrant women. CONCLUSIONS Our study highlights the complexity of discussing stillbirth during pregnancy. The women in this study were found to receive a wide range of advice from family and friends as well as health professionals about how to keep their baby safe in pregnancy, they recommended the development of a range of resources to provide clear and consistent messages. Health professionals, in particular midwives who have developed a trusting relationship with the women will be key to ensuring that public health messages relating to stillbirth reduction are accessible to culturally and linguistically diverse communities.
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Affiliation(s)
- Tomasina Stacey
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, United Kingdom.
- Calderdale and Huddersfield NHS Foundation Trust, Lindley, Huddersfield, United Kingdom.
| | | | - Nisa Almas
- Faculty of Heath Studies, University of Bradford, Bradford, United Kingdom
| | - Charlotte Kenyon
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, United Kingdom
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