Dietary supplements, guideline alignment and biochemical nutrient status in pregnancy: Findings from the Queensland Family Cohort pilot study

In high-income nations, multiple micronutrient (MMN) supplementation during pregnancy is a common practice. We aimed to describe maternal characteristics associated with supplement use and daily dose of supplemental nutrients consumed in pregnancy, and whether guideline alignment and nutrient status are related to supplement use. The Queensland Family Cohort is a prospective, Australian observational longitudinal study. Maternal characteristics, nutrient intake from food and supplements, and biochemical nutrient status were assessed in the second trimester (n = 127). Supplement use was reported by 89% of participants, of whom 91% reported taking an MMN supplement. Participants who received private obstetric care, had private health insurance and had greater alignment to meat/vegetarian alternatives recommendations were more likely to report MMN supplement use. Private obstetric care and general practitioner shared care were associated with higher daily dose of supplemental nutrients consumed compared with midwifery group practice. There was high reliance on supplements to meet nutrient reference values for folate, iodine and iron, but only plasma folate concentrations were higher in MMN supplement versus nonsupplement users. Exceeding the upper level of intake for folic acid and iron was more likely among combined MMN and individual supplement/s users, and associated with higher plasma concentrations of the respective nutrients. Given the low alignment with food group recommendations and potential risks associated with high MMN supplement use, whole food diets should be emphasized. This study confirms the need to define effective strategies for optimizing nutrient intake in pregnancy, especially among those most vulnerable where MMN supplement use may be appropriate.

A prospective observational evaluation of an online health care professional training program to promote healthy pregnancy weight gain

ISSUE ADDRESSED

A lack of programs to develop clinician knowledge and confidence to address weight gain within pregnancy is a barrier to the provision of evidence-based care.

AIM

To examine the reach and effectiveness of the Healthy Pregnancy Healthy Baby online health professional training program.

METHODS

A prospective observational evaluation applied the reach and effectiveness elements of the RE-AIM framework. Health professionals from a range of disciplines and locations were invited to complete questionnaires before and after program completion assessing objective knowledge and perceived confidence around aspects of supporting healthy pregnancy weight gain, and process measures.

RESULTS

There were 7577 views across all pages over a year period, accessed by participants across 22 Queensland locations. Pre- and post- training questionnaires were completed 217 and 135 times, respectively. The proportion of participants with scores over 85% and of 100% for objective knowledge was higher post training (P ≤ .001). Perceived confidence improved across all areas for 88%-96% of those who completed the post- training questionnaire. All respondents would recommend the training to others.

CONCLUSIONS

Clinicians from a range of disciplines, experience and locations accessed and valued the training, and knowledge of, and confidence in delivering care to support healthy pregnancy weight gain improved after completion. SO WHAT?: This effective program to build the capacity of clinicians to support healthy pregnancy weight gain offers a model for online, flexible training highly valued by clinicians. Its adoption and promotion could standardise the support provided to women to encourage healthy weight gain during pregnancy.

Preventing Gestational Diabetes with a Healthy Gut Diet: Protocol for a Pilot, Feasibility Randomized Controlled Trial

Around 14% of pregnancies globally are affected by gestational diabetes mellitus (GDM), making it one of the most common disorders experienced by women in pregnancy. While dietary, physical activity and supplement interventions have been implemented to prevent GDM, with varying levels of success, altering the gut microbiota through diet is a promising strategy for prevention. Several studies have demonstrated that women with GDM likely have a different gut microbiota to pregnant women without GDM, demonstrating that the gut microbiota may play a part in glycemic control and the development of GDM. To date, there have been no randomized controlled trials using diet to alter the gut microbiota in pregnancy with the aim of preventing GDM. Here, we present the study protocol for a single-blind randomized controlled trial which aims to determine the effectiveness of the Healthy Gut Diet on reducing the diagnosis of GDM in pregnant women with one or more risk factors. Consenting women will be randomized into either the Healthy Gut Diet intervention group or the usual care (control) group after 11 weeks gestation. The women in the intervention group will receive three telehealth counseling appointments with an Accredited Practicing Dietitian with the aim of educating and empowering these women to build a healthy gut microbiota through their diet. The intervention was co-designed with women who have lived experience of GDM and incorporates published behavior change techniques. The control group will receive the usual care and will also be shown a brief (3 min) video on general healthy eating in pregnancy. The primary outcome is the diagnosis of GDM at any stage of the pregnancy. Secondary outcomes include changes to gut microbiota composition and diversity; gestational weight gain; maternal and infant outcomes; management of GDM (where relevant); dietary quality and intake; physical activity; and depression scoring. We aim to recruit 120 women over 16 months. Recruitment commenced in January 2023. The trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622001285741).

Barriers to and facilitators of a healthy lifestyle for patients with gynecological cancer: a systematic review of qualitative and quantitative research with healthcare providers and patients

The prevalence of an unhealthy lifestyle among patients with gynecological cancer is high and associated with increased risk of all-cause mortality. Although lifestyle changes have the potential to improve outcomes, lifestyle counseling is not routinely integrated into standard care. This review explores research on the barriers to and facilitators of both the promotion of healthy lifestyles by healthcare providers (HCPs) and healthy lifestyle changes by patients with gynecological cancer. The Theoretical Domains Framework (TDF) was used to deductively code the identified factors for a comprehensive understanding of the barriers and facilitators. A search across five databases yielded a total of 12,687 unique studies, of which 43 were included in the review. Of these 43, 39 included gynecological cancer patients and only 6 included HCPs. Among the barriers identified for HCPs, most studies evaluated barriers regarding weight loss counseling. Limited knowledge, reluctance to address weight loss, skepticism about the benefits, and workload concerns were commonly reported barriers for HCPs. HCPs will benefit from education and training in lifestyle counseling, including effective communication skills like motivational interviewing. Gynecological cancer patients lacked tools, support, knowledge, and faced mental health issues, environmental constraints, and physical limitations. The review emphasizes the importance of addressing these barriers and utilizing identified facilitators, such as social support, to promote and support healthy lifestyle behaviors on the part of patients and their promotion by HCPs. Future research should focus not only on patients but also on supporting HCPs and implementing necessary changes in current practices.

Digital preconception interventions targeting weight, diet and physical activity: A systematic review

AIM

Optimising preconception health increases the likelihood of conception, positively influences short- and long-term pregnancy outcomes and reduces intergenerational chronic disease risk. Our aim was to synthesise study characteristics and maternal outcomes of digital or blended (combining face to face and digital modalities) interventions in the preconception period.

METHODS

We searched six databases (PubMed, Cochrane, Embase, Web of Science, CINHAL and PsycINFO) from 1990 to November 2022 according to the PRISMA guidelines for randomised control trials, quasi-experimental trials, observation studies with historical control group. Studies were included if they targeted women of childbearing age, older than 18 years, who were not currently pregnant and were between pregnancies or/and actively trying to conceive. Interventions had to be delivered digitally or via digital health in combination with face-to-face delivery and aimed to improve modifiable behaviours, including dietary intake, physical activity, weight and supplementation. Studies that included women diagnosed with type 1 or 2 diabetes were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality criteria checklist. Study characteristics, intervention characteristics and outcome data were extracted.

RESULTS

Ten studies (total participants n=4,461) were included, consisting of nine randomised control trials and one pre-post cohort study. Seven studies received a low risk of bias and two received a neutral risk of bias. Four were digitally delivered and six were delivered using blended modalities. A wide range of digital delivery modalities were employed, with the most common being email and text messaging. Other digital delivery methods included web-based educational materials, social media, phone applications, online forums and online conversational agents. Studies with longer engagement that utilised blended delivery showed greater weight loss.

CONCLUSION

More effective interventions appear to combine both traditional and digital delivery methods. More research is needed to adequately test effective delivery modalities across a diverse range of digital delivery methods, as high heterogeneity was observed across the small number of included studies.

Gestational diabetes mellitus care re-imagined - A cost-minimisation analysis: Cost savings from a tertiary hospital, using a novel, digital-based gestational diabetes management model

BACKGROUND

Diagnosis of gestational diabetes mellitus (GDM) in a pregnancy has a significant impact on health service resources and represents a substantial financial and time impost on women.

AIM

To describe a cost-minimisation analysis conducted following the demonstration of clinically equivalent care of women using a novel, digital model for GDM management, compared with conventional care.

MATERIALS AND METHODS

A pre-implementation model of care was compared with the post-implementation model of care which included systematic development and delivery of education videos, use of the Commonwealth Scientific and Industrial Research Organisation 'M♡THer' smart phone app/portal and a dramatically reduced schedule of visits. The Mater Mothers' Hospital Brisbane cares for approximately 1200 women with GDM per annum, on which the cost estimates were based. Service costs were estimated using the resource method, where resource volumes and costs were gathered from experts within the health service. Patient costs were estimated using results from a short survey completed by a cohort of the study population.

RESULTS

Health service costs showed a modest saving of AU$17 441.78 (US$12 158.92) in the intervention group over a 12-month period. Cost savings for the woman were estimated at $566.56 (US$394.96) per patient after accounting for lost wages, childcare expenses, and travel expenses avoided. This reduction led to an overall saving of $679 872 (US$473 948.82) for the cohort of 1200 women, primarily due to the reduction in face-to-face visits.

CONCLUSION

Re-imagining GDM patient care by introducing a novel, digital-based GDM model of care has substantial positive cost implications for patients.

GDM care re-imagined: Maternal and neonatal outcomes following a major model of care change for gestational diabetes mellitus at a large metropolitan hospital

BACKGROUND

The rapidly rising prevalence of gestational diabetes mellitus (GDM) poses major challenges to the efficient, timely and sustainable provision of diabetes care.

AIM

To assess whether the implementation of a novel, digital model of care would provide improved efficiency without compromising clinical outcomes in a cohort of women with GDM.

METHODS

A digital model of care was developed, implemented and evaluated using a prospective pre-post study design in 2020-21 at a quaternary centre. We introduced six culturally and linguistically tailored educational videos, home delivery of equipment and prescriptions, and a smartphone app-to-clinician portal for glycaemic review and management. Outcomes were prospectively recorded by an electronic medical record. Associations between model of care and maternal and neonatal characteristics and birth outcomes were examined for all women and separately by treatment received (diet, metformin, insulin).

RESULTS

Comparing pre-implementation (n = 598) and post-implementation (n = 337) groups, maternal (onset, mode of birth) and neonatal (birthweight, large for gestational age (LGA), nursery admission) clinical outcomes confirmed that the novel model of care was similar to standard, traditional care. Minor birthweight variation was noted when separated by treatment type (diet, metformin, insulin).

CONCLUSION

This pragmatic service redesign demonstrates reassuring clinical outcomes in a culturally diverse GDM cohort. Despite the lack of randomisation, this intervention has potential generalisability for GDM care and important key learnings for service redesign in the digital era.

Co-designing nutrition interventions with consumers: A scoping review

BACKGROUND

There is little known about nutrition intervention research involving consumer co-design. The aim of this scoping review was to identify and synthesise the existing evidence on the current use and extent of consumer co-design in nutrition interventions.

METHODS

This scoping review is in line with the methodological framework developed by Arksey and O'Malley and refined by the Joanna Briggs Institute using an adapted 2weekSR approach. We searched Medline, EMBASE, PsycInfo, CINAHL and Cochrane. Only studies that included consumers in the co-design and met the 'Collaborate' or 'Empower' levels of the International Association of Public Participation's Public Participation Spectrum were included. Studies were synthesised according to two main concepts: (1) co-design for (2) nutrition interventions.

RESULTS

The initial search yielded 8157 articles, of which 19 studies were included (comprising 29 articles). The studies represented a range of intervention types and participants from seven countries. Sixteen studies were published in the past 5 years. Co-design was most often used for intervention development, and only two studies reported a partnership with consumers across all stages of research. Overall, consumer involvement was not well documented. No preferred co-design framework or approach was reported across the various studies.

CONCLUSIONS

Consumer co-design for nutrition interventions has become more frequent in recent years, but genuine partnerships with consumers across all stages of nutrition intervention research remain uncommon. There is an opportunity to improve the reporting of consumer involvement in co-design and enable equal partnerships with consumers in nutrition research.

Improving Engagement in Antenatal Health Behavior Programs-Experiences of Women Who Did Not Attend a Healthy Lifestyle Telephone Coaching Program

Living Well during Pregnancy (LWdP) is a telephone-based antenatal health behavior intervention that has been shown to improve healthy eating behaviors and physical activity levels during pregnancy. However, one-third of eligible, referred women did not engage with or dropped out of the service. This study aimed to explore the experiences and perceptions of women who were referred but did not attend or complete the LWdP program to inform service improvements and adaptations required for scale and spread and improve the delivery of patient-centered antenatal care. Semi-structured telephone interviews were conducted with women who attended ≤2 LWdP appointments after referral. The interviews were thematically analyzed and mapped to the Theoretical Domains Framework and Behavior Change Wheel/COM-B Model to identify the barriers and enablers of program attendance and determine evidence-based interventions needed to improve service engagement and patient-centered antenatal care. Three key themes were identified: (1) the program content not meeting women's expectations and goals; (2) the need for flexible, multimodal healthcare; and (3) information sharing throughout antenatal care not meeting women's information needs. Interventions to improve women's engagement with LWdP and patient-centered antenatal care were categorized as (1) adaptations to LWdP, (2) training and support for program dietitians and antenatal healthcare professionals, and (3) increased promotion of positive health behaviors during pregnancy. Women require flexible and personalized delivery of the LWdP that is aligned with their individual goals and expectations. The use of digital technology has the potential to provide flexible, on-demand access to and engagement with the LWdP program, healthcare professionals, and reliable health information. All healthcare professionals are vital to the promotion of positive health behaviors in pregnancy, with the ongoing training and support necessary to maintain clinician confidence and knowledge of healthy eating, physical activity, and weight gain during pregnancy.

Informing a healthy eating and physical activity program to decrease postnatal weight retention: What are women experiencing and what type of program do they want?

ISSUE ADDRESSED

Retention of weight gained during pregnancy contributes to overweight and obesity and consequent chronic disease risk. Early programs have been successful in improving diet quality, physical activity levels and reducing postnatal weight retention. However, barriers to program engagement remain. This study aimed to investigate women's healthy eating, physical activity and weight experiences and explore their views regarding digital health interventions to assist meeting their lifestyle goals.

METHODS

This qualitative descriptive study utilised semi-structured interviews with women who had recently become mothers who had gestational diabetes or a body mass index above 25 kg/m² . Themes were then identified through thematic analysis of interview transcripts.

RESULTS

Nine women were interviewed (average age 33.4 ± 4.2 years). The two distinct areas of questioning resulted in two overarching topics: (i) Enablers and barriers to maintaining regular physical activity and a healthy dietary pattern; and (ii) characteristics of a postpartum program to enable meeting of diet, physical activity and weight loss goals. These topics each had their own descriptive themes and sub-themes.

CONCLUSIONS

Understanding women's needs and viewpoints for a postnatal diet, physical activity and weight program allows researchers to design a program to maximise engagement and outcomes. SO WHAT?: Any further postnatal program must leverage off existing infrastructure, integrate learnings from published formative work and harnesses the impact of digital delivery. This will improve program accessibility and provide ongoing contact for sustained behaviour change through text messaging and providing digital resources in a dynamic format women can engage with in their own time.

Evaluation of the Pragmatic Implementation of a Digital Health Intervention Promoting Healthy Nutrition, Physical Activity, and Gestational Weight Gain for Women Entering Pregnancy at a High Body Mass Index

txt4two is a multi-modality intervention promoting healthy pregnancy nutrition, physical activity (PA), and gestational weight gain (GWG), which had been previously evaluated in a pilot randomized controlled trial (RCT). This study aimed to evaluate a pragmatic implementation of an adapted version of txt4two in a public tertiary hospital. Using a consecutive cohort design, txt4two was delivered to women with a pre-pregnancy BMI > 25 kg/m², between 10 + 0 to 17 + 6 weeks. Control and intervention cohorts (n = 150) were planned, with surveys and weight measures at baseline and 36 weeks. The txt4two cohort received a dietetic goal-setting appointment and program (SMS, website, and videos). The navigation of disparate hospital systems and the COVID-19 pandemic saw adaptation and adoption take two years. The intervention cohort (n = 35; 43% full data) demonstrated significant differences (mean (SD)), compared to the control cohort (n = 97; 45% full data) in vegetable intake (+0.9 (1.2) versus +0.1 (0.7), p = 0.03), fiber-diet quality index (+0.6 (0.8) versus 0.1 (0.5), p = 0.012), and total diet quality index (+0.7 (1.1) versus +0.2 (±0.6), p = 0.008), but not for PA or GWG. Most (85.7%) intervention participants found txt4two extremely or moderately useful, and 92.9% would recommend it. Embedding the program in a non-RCT context raised implementation challenges. Understanding the facilitators and barriers to adaptation and adoption will strengthen the evidence for the refinement of implementation plans.

Gut microbiome composition is similar between pregnant women with excess body fat with healthy and less healthy dietary intake patterns

BACKGROUND

Dietary composition influences the composition of the gut microbiota in healthy adults. Little is known about the effect of dietary patterns on gut microbiota composition in pregnancy. This cross-sectional study aimed to investigate the associations between two diet quality scores adapted from the Australian Recommended Food Score (ARFS) and the Mediterranean Dietary Score (MDS) with the composition of the gut microbiota in pregnant women with excess body fat at 28 weeks' gestation.

METHODS

Women from the Study of Probiotics IN Gestational diabetes (SPRING) who had completed a food frequency questionnaire (FFQ; n = 395) were classified according to tertiles of ARFS and the MDS. Higher dietary pattern scores in both the ARFS and the MDS represent better diet quality. Gut microbiota composition was assessed using 16S rRNA gene amplicon sequencing and analysed using MicrobiomeAnalyst in a subset of 196 women with faecal samples.

RESULTS

No significant difference was found in alpha or beta diversity. A higher ARFS was associated with a higher abundance of Ruminococcus and lower abundance of Akkermansia, whereas a higher MDS was associated with a higher abundance of Ruminococcus and Butyricicoccus, though these changes disappeared after correction for multiple testing.

CONCLUSION

These results suggest that dietary patterns defined by the ARFS and MDS were not associated with gut microbiota composition in pregnant women classified as overweight and obese at 28 weeks' gestation within this study.

Exploring the diets of mothers and their partners during pregnancy: Findings from the Queensland Family Cohort pilot study

AIM

Modifiable behaviours during the first 1000 days of life influence developmental trajectories of adult chronic diseases. Despite this, sub-optimal dietary intakes during pregnancy and excessive gestational weight gain are common. Very little is known about partners' dietary patterns and the influence on women's pregnancy dietary patterns. We aimed to examine dietary intake during pregnancy among women and their partners, and gestational weight gain patterns in the Queensland Family Cohort pilot study.

METHODS

The Queensland Family Cohort is a prospective, observational study piloted at a Brisbane (Australia) tertiary maternity hospital from 2018 to 2021. Participant characteristics, weight gain, dietary and nutrient intake were assessed.

RESULTS

Data were available for 194 pregnant women and their partners. Poor alignment with Australian Guide to Healthy Eating recommendations was observed. Highest alignment was for fruit (40% women) and meat/alternatives (38% partners) and lowest for breads/cereals (<1% women) and milk/alternatives (13% partners). Fewer women (4.4%-60.3%) than their partners (5.4%-92.3%) met guidelines for all micronutrient intakes from food alone, particularly folic acid, iodine, and iron. Women were more likely to meet daily recommendations for fruit, vegetables, dairy, bread/cereals, and meat/alternatives when their partners also met recommendations. Women with a higher pre-pregnancy body mass index were more likely to gain above recommended weight gain ranges.

CONCLUSIONS

In this contemporary cohort of pregnant women and their partners, sub-optimal dietary patterns and deficits in some nutrients were common. There is an urgent need for evidence-informed public health policy and programs to improve diet quality during pregnancy due to intergenerational effects.

Using the Consolidated Framework for Implementation Research to design and implement a perinatal education program in a large maternity hospital

BACKGROUND

Implementation science aims to embed evidence-based practice as 'usual care' using theoretical underpinnings to guide these processes. Conceptualising the complementary purpose and application of theoretical approaches through all stages of an implementation project is not well understood and is not routinely reported in implementation research, despite call for this. This paper presents the synthesis and a collective approach to application of a co-design model, a model for understanding need, theories of behaviour change with frameworks and tools to guide implementation and evaluation brought together with the Consolidated Framework for Implementation Research (CFIR).

METHOD

Using a determinant framework such as the CFIR provides a lens for understanding, influencing, and explaining the complex and multidimensional variables at play within a health service that contribute to planning for and delivering effective patient care. Complementary theories, models, frameworks, and tools support the research process by providing a theoretical and practical structure to understanding the local context and guiding successful local implementation.

RESULTS

This paper provides a rationale for conceptualising the multidimensional approach for implementation using the worked example of a pregnancy, birth, postnatal and early parenting education intervention for expectant and new parents at a large maternity hospital.

CONCLUSION

This multidimensional theoretical approach provides useful, practical guidance to health service researchers and clinicians to develop project specific rationale for their theoretical approach to implementation projects.

Consumption of a Low Carbohydrate Diet in Overweight or Obese Pregnant Women Is Associated with Longer Gestation of Pregnancy

Studies of obstetric outcomes in women consuming low-carbohydrate diets have reported conflicting results. Most studies have defined low-carbohydrate diets by the percentage that carbohydrates contribute to overall energy intake, rather than by an absolute amount in grams per day (g/d). We hypothesised that a low absolute carbohydrate diet affects obstetric outcomes differently than a low percentage carbohydrate diet. Dietary data were collected from overweight or obese women in the Study of Probiotic IN Gestational diabetes at 16- and 28-weeks’ gestation. Obstetric outcomes were compared between women whose carbohydrate intake was in the lowest quintile vs quintiles 2–5. Mean gestation was increased in women whose absolute carbohydrate intake was in the lowest quintile at 16 and at both 16- and 28-weeks’ gestation compared with all other women (16: 39.7 vs. 39.1 weeks, p = 0.008; 16 and 28: 39.8 vs. 39.1, p = 0.005). In linear regression analysis, a low absolute carbohydrate intake at 16 and at 28 weeks’ gestation was associated with increased gestation at delivery (16: p = 0.04, adjusted R² = 0.15, 28: p = 0.04, adjusted R² = 0.17). The coefficient of beta at 16 weeks’ gestation was 0.50 (95% CI 0.03–0.98) and at 28 weeks’ gestation was 0.51 (95%CI 0.03–0.99) meaning that consumption of a low absolute carbohydrate diet accounted for an extra 3.5 days in gestational age. This finding was not seen in women whose percentage carbohydrate intake was in the lowest quintile. Low-carbohydrate consumption in pregnancy is associated with increased gestational age at delivery.

Implementation science for dietitians: The 'what, why and how' using multiple case studies

AIM

Implementation science theories, models and frameworks help to address evidence-practice gaps, which have increasing importance for dietetic practice. This paper aims to provide dietitians with insight into how implementation science can be applied to practice, using multiple 'real-life' case studies.

METHODS

Three case studies were purposively selected across areas of dietetics practice to demonstrate application of commonly-used implementation theories, models and frameworks. Reflections from the authors were provided in response to a structured set of questions outlining how the theoretical approach was selected and used, and considerations for future application. Within and cross-case analysis was undertaken.

RESULTS

Dietitians used diverse implementation theories, models and frameworks to identify barriers and enablers, to plan for implementation, and to guide the selection of implementation strategies. Implementation theory was used to evaluate the implementation process in one case study. Cross-case analysis identified that mentoring by those with implementation expertise, multidisciplinary implementation teams, and leadership and investment in research and translation at an organisational and departmental level as key enablers.

CONCLUSIONS

This paper offers dietitians insight into how implementation science can be applied to improve the uptake of evidence-based practices within nutrition and dietetics, and suggests that there needs to be investment in implementation science as a foundation science within nutrition and dietetics, including education, training and mentoring for dietitians.

Using the theoretical domains framework to inform strategies to support dietitians undertaking body composition assessments in routine clinical care

BACKGROUND

Malnutrition, sarcopenia and cachexia are clinical wasting syndromes characterised by muscle loss. Systematic monitoring by body composition assessment (BCA) is recommended for the diagnosis, treatment and monitoring of the syndrome(s). This study investigated practices, competency, and attitudes of Australian dietitians regarding BCA, to inform a local implementation process.

METHODS

Applying the Action cycle in the Knowledge to Action framework, surveys were distributed to the 26 dietitians of an 800-bed tertiary hospital. The survey assessed barriers and enablers to performing routine BCA in clinical care. Results were categorised using the Theoretical Domains Framework (TDF) and suitable interventions mapped using the Behaviour Change Wheel.

RESULTS

Twenty-two dietitians (84.6%) completed the survey. Barriers to BCA were identified in all TDF domains, particularly in Knowledge, Skills, Social/professional role and identity, Beliefs about capabilities, and Environmental context and resources. Enablers existed in domains of: Skills; Beliefs about consequences; Goals; Environmental context and resources; Social influences; Intentions; Optimism; Reinforcement.

CONCLUSIONS

This study showed that hospital dietitians experience individual, team, and organisational barriers to adopt BCAs in clinical practice. We were able to formulate targeted implementation strategies to overcome these barriers to assist BCA adoption into routine practice.

Searching for Utopia, the Challenge of Standardized Medical Nutrition Therapy Prescription in Gestational Diabetes Mellitus Management: A Critical Review

Gestational diabetes mellitus (GDM) is a common pregnancy disorder and the incidence is increasing worldwide. GDM is associated with adverse maternal outcomes which may be reduced with proper management. Lifestyle modification in the form of medical nutrition therapy and physical activity, as well as self-monitoring of blood glucose levels, is the cornerstone of GDM management. Inevitably, the search for the "ultimate" diet prescription has been ongoing. Identifying the amount and type of carbohydrate to maintain blood glucose levels below targets while balancing the nutritional requirements of pregnancy and achieving gestational weight gain within recommendations is challenging. Recent developments in the area of the gut microbiota and its impact on glycemic response add another layer of complexity to the success of medical nutrition therapy. This review critically explores the challenges to dietary prescription for GDM and why utopia may never be found.

Knowledge Translation in Dietetics: A Survey of Dietitians' Awareness and Confidence

This study aimed to determine dietitians' familiarity with knowledge translation (KT), confidence in undertaking KT, and preferences for receiving KT training. An online questionnaire was designed and disseminated to all dietitians working across hospital and health services in Queensland, Australia, for completion over a 6-week period (April-May 2018). Of the 124 respondents, 69% (n = 85) reported being familiar with KT, but only 28% (n = 35) reported being confident in applying KT to their practice. Higher confidence was reported with problem identification, evidence appraisal, and adapting evidence to local context, compared with implementation, evaluation, and dissemination. Almost all respondents reported an interest in learning more about KT (n = 121, 98%), with a preference for easily accessible and short "snippets" of training aimed at beginner-intermediate level. Lack of management support, difficulty attending multi-day courses, cost, travel requirements, and lack of quarantined time were reported barriers to attending KT training. There is a high awareness and interest but low confidence in undertaking KT amongst dietitians. This highlights an opportunity for workforce development to prepare dietitians to be skilled and confident in KT. Training and support needs to be low-cost and multi-modal to meet diverse needs.

Nutrition process improvements for adult inpatients with inborn errors of metabolism using the i-PARIHS framework

AIM

This project aimed to implement consensus recommendations and innovations that improve dietetic services to promote timely referral to optimise nutritional management for adult inpatients with inborn errors of metabolism (IEM).

METHODS

The i-PARIHS framework was used to identify service gaps, implement innovations and evaluate the innovations within this single-site study. The constructs of this framework are: (i) review of the evidence; (ii) recognising patients and staff knowledge and attitudes; (iii) acknowledging the local context; and (iv) the facilitators role. This included a literature review and metabolic centre service comparisons to investigate dietetic referral and foodservice processes to inform the innovation. A 12-month chart audit (6 months retrospective and prospective of implemented innovation, respectively) to evaluate newly established dietetic referral and IEM nutrition provision procedures was also completed.

RESULTS

The innovations implemented encompassed a clinical alert triggering urgent referral, nutrition sick day plans and metabolic diet and formula prescription via an 'alert' tab in electronic records. Eleven metabolic protein-restricted diets and nine formula recipes were introduced. Prior to the innovations, only 53% (n = 19/36) of inpatients with IEM were assessed by the dietitian and received appropriate nutrition within 24 hours. Following implementation of the innovations, 100% (n = 11/11) of inpatients with IEM received timely dietetic assessment and therapeutic nutrition.

CONCLUSIONS

Implementation of innovations developed using the i-PARIHS framework is effective in timely notification of the metabolic dietitian of referrals. This ensures optimal nutritional management during admissions which is required in this group of high-risk patients.

Implementing a best-practice model of gestational diabetes mellitus care in dietetics: a qualitative study

Background

Translating research into clinical practice is challenging for health services. Emerging approaches in implementation science recognise the need for a theory–driven approach to identify and overcome barriers to guideline adherence. However, many clinicians do not have the capacity, confidence, or expertise to realise change in their local settings. Recently, two regional sites participated in a facilitated implementation project of an evidence-based model of gestational diabetes mellitus (GDM) care in dietetics, supported by a team at a metropolitan centre. This study describes (i) stakeholder experiences’, and (ii) learnings to inform implementation of the model of care (MOC) across Queensland.

Methods

This qualitative descriptive study utilised semi-structured telephone interviews with staff involved in implementation of the MOC project at two regional sites. Eight participants were recruited; five participants were from one site. Interviews were transcribed and analysed to identify recurrent themes.

Results

Four main themes were derived: (1) catalyst for positive change, (2) managing project logistics, (3) overcoming barriers, and (4) achieving change.

Conclusions

A model of external facilitated implementation using an evidence-based decision making tool is an effective method of fostering health service change and is acceptable to staff. Key elements of the facilitation were building confidence and capacity in local implementers, through regular contact, encouraging local networking, linking to higher management support and assessing and/or influencing workplace or organizational culture. However, the balance between delivering clinical care while participating in a service change project proved challenging to many participants.

Low dietary fiber intake increases Collinsella abundance in the gut microbiota of overweight and obese pregnant women

The gut microbiota contributes to the regulation of glucose metabolism in pregnancy. Abundance of the genus Collinsella is positively correlated with circulating insulin; however, it is unclear what determines Collinsella abundance. This study aims to validate the correlation between Collinsella and insulin and to elucidate if macronutrient intake alters Collinsella abundance and gut microbiota composition. Gut microbiota profiles were assessed by 16S rRNA sequencing in 57 overweight and 73 obese pregnant women from the SPRING (Study of PRobiotics IN Gestational diabetes) trial at 16 weeks gestation and correlated with metabolic hormone levels and macronutrient intake. Gut microbiota composition in the top and bottom 10% of dietary fiber intake was evaluated through network analysis. Collinsella abundance correlated positively with circulating insulin (rho = 0.30, p = 0.0006), independent of maternal BMI, but negatively with dietary fiber intake (rho = -0.20, p = 0.025) in this cohort. Low dietary fiber intake was associated with a gut microbiota favoring lactate fermentation while high fiber intake promotes short-chain fatty acid-producing bacteria. Low dietary fiber may enable overgrowth of Collinsella and alter the overall fermentation pattern in gut microbiota. This suggests that dietary choices during pregnancy can modify the nutritional ecology of the gut microbiota, with potential deleterious effects on the metabolic and inflammatory health of the host.

TRIAL REGISTRATION

ANZCTR 12611001208998, registered 23/11/2011.

Clinically relevant improvements achieved from a facilitated implementation of a gestational diabetes model of care

AIM

Medical nutrition therapy is a cornerstone treatment in gestational diabetes; however, most Australian women diagnosed with gestational diabetes do not receive this. The project evaluated adaptation of a successful evidence-based gestational diabetes model of care implementation from a tertiary centre into regional sites with varied demographics, population size and service capacity.

METHODS

The project used a hub (project team)-spoke (sites) model in Far North Queensland (Site 1) and regional South-East Queensland (Site 2). Sites selected demonstrated strong gestational diabetes team cohesiveness and project commitment. The project phases were consultation, baseline, transition and implementation. A best practice decision tree tool was provided to assess/manage barriers to the model of care and clinical outcomes captured through a project database.

RESULTS

Role clarification of site members, management engagement, site visits, decision tree and database refinement were completed in the project's first phase. Unexpected organisational and team barriers prevented timeline implementation as planned. Sites negotiated relevant reallocation of resources to achieve project deliverables. The proportion of women seen according to best practice increased from 3.5 to 87.8% (P < 0.001) (Site 1) and nil to 4.8% (P = 0.09) (Site 2), and those on medication dropped by 3.4 (Site 1) and 9.1% (Site 2).

CONCLUSIONS

This project demonstrates a successful implementation using a facilitated and rigorous approach. Support, engagement and tools at many levels were keys to success at both sites. The present study illustrates the opportunities and challenges of conducting implementation research within routine clinical care, particularly in resource-challenged sites.

Development and pilot testing of a parent-reported health-related quality of life measure for children on the ketogenic diet: The KetoQoL

AIM

The aim of the present study was to develop a parent-reported tool that will measure health-related quality of life (HRQoL) in children following ketogenic diet (KD) therapies for refractory epilepsy once it has been pilot tested and analysed.

METHODS

Parents of children following KD therapies for epilepsy were recruited through a public hospital in Queensland, Australia, in 2012 and 2014. Qualitative semistructured interviews were conducted in 2012 with 13 parents who described changes seen in their child's HRQoL while on the KD. A quality of life tool (QoL) was developed by adapting the Quality of Life in Childhood Epilepsy tool based on results and themes analysed from the interviews. The KetoQoL was pilot tested with 18 parents recruited in 2014. Interrelationships between variables and questions were explored with exploratory factor analysis (EFA) to determine which questions had the greatest effect on QoL.

RESULTS

The first iteration of the KetoQoL consisted of five main domains: physical, cognitive, social, intrapersonal and effects on the family. The domains were subdivided into 18 variables, totalling 54 items. EFA demonstrated that items from the physical and effects on the family domains had the greatest effect on QoL.

CONCLUSIONS

KetoQoL is an HRQoL tool developed using a range of methods and assessed for both face and content validity. Further testing of KetoQoL is required to refine and confirm the factors. This work will enhance the evaluation of treatment effectiveness in children with epilepsy following the KD.

Integrated care among healthcare providers in shared maternity care: what is the role of paper and electronic health records?

This study examines a paper hand-held record and a shared electronic health record in an Australian tertiary hospital healthcare maternity setting and the role that both types of records play in facilitating integrated care among healthcare providers. A qualitative research design was used where five focus groups were conducted in two phases with 69 hospital healthcare providers. In total, 32 interviews were also carried out with general practitioners. Transcripts were analysed using qualitative content analysis. Three key themes were identified: (1) selective use of records; (2) records as communication of care; and (3) negativity about the use of records. This study demonstrates that healthcare providers do not effectively share information using either a paper hand-held record or a shared electronic health record. Considering a national commitment to e-health innovation, a multi-professional input, organisational support and continuing education are identified as crucial to realising the potential of a maternity shared electronic health record to facilitate integrated care.

Service-wide management of healthy gestational weight gain following an implementation science approach

The aim of health guidelines is to ensure consistency in the delivery of care to minimise health-related complications. However, even when good evidence is available, professionals do not necessarily implement it. Following a 2011 survey (Time 1) of staff in a tertiary maternity hospital, a number of service changes were implemented to facilitate best practice delivery of care to pregnant women regarding gestational weight gain (GWG). A (second) staff survey was then undertaken to re-assess staff knowledge, attitudes and behaviours around the management of GWG in our hospital. This cross-sectional, prospective online survey was distributed to staff in antenatal clinic. The survey assessed staff awareness of pregnancy-related weight complications, knowledge and application of specific guidelines, and a guideline adherence score was calculated. Sixty-nine staff (44.8% response rate) completed the 2014 (Time 2) survey. Just over half (51.9%) stated they were familiar with clinical guidelines regarding weight management in pregnancy. Guideline adherence ranged from 3.7 ± 1.9 to 11.3 ± 1.0 /15 across different professional groups; significant improvements with adherence by dietitians were noted over time. Despite minimal change over time in the overall adherence score, compliance with individual elements of the guideline recommendations comprising the adherence score differed. Improvements in staff practices and attitudes are apparent since the first survey. However, further improvements in guideline awareness and guideline elements are still required to improve the delivery of best practice antenatal GWG care.

An Evidence-Based Approach to Influencing Evidence-Based Practice in Allied Health

BACKGROUND

Factors affecting the evidence-based practice (EBP) capabilities of allied health staff are complex and are linked with institutional barriers, personal self-belief, and individual experience and ability. This study's aim was to measure the effect of training and organisational change on EBP measures among allied health staff.

METHODS

Sixty-three percent of allied health hospital staff (201/303) completed an online survey measuring constructs of EBP. Results were compared to those from the same survey conducted in the previous year, with a response rate of 72.2% (182/252). Eighty staff completed the survey at both time points. Independent and repeated measures ANOVAs were used to compare levels of self-efficacy, outcome expectancy, knowledge, and use, according to discipline over time.

RESULTS

A significant increase in EBP self-efficacy was observed over time (p=0.03), as well as amongst staff who completed the survey at both time points (p=0.013). Significant differences existed between professions at time 2 in EBP-outcome expectancy (p=0.002) and EBP use (p=0.016).

CONCLUSIONS

Targeted within-department and general allied health workplace evidence-based interventions to improve EBP constructs have been effective at improving overall allied health EBP self-efficacy. Different departments have demonstrated individual improvements in EBP scores, potentially reflecting different training and organisational strategies implemented across departments.

Reassessment of Allied Health Professionals' Level of Self-Efficacy in, Outcome Expectancy in, and Use of Evidence-Based Practice

AIM

Evidence-based practice (EBP) is fundamental to improving patient outcomes. Factors affecting EBP capabilities are linked with institutional culture and barriers, personal self-belief, and individual ability. To effect change in capabilities, interventions must target barriers and be informed by behaviour change theory. This study measured the effect of training and organisational change on EBP measures amongst allied health professionals.

METHODS

All allied health staff (n=196) employed across the Mater Health Services (Brisbane, Queensland) were invited to complete a survey assessing EBP self-efficacy, outcome expectancy and use, as well as EBP training undertaken. Data were compared with those of surveys from 2010 and 2011.

RESULTS

Response rate was 70.9% (n=139/196); 32 staff completed all surveys. Significant improvements were observed in staff undertaking training (EBP, p=0.008; research design and analysis, p=0.003) since the first survey. The significant increase in EBP self-efficacy that occurred from T1 to T2 remained at T3 (p=0.008). Fewer between-department differences were observed over time.

CONCLUSIONS

This study identified sustained EBP self-efficacy improvements in this cohort and found that between-department differences have virtually disappeared. Ongoing interventions are required to sustain and improve staff's belief in their ability to deliver EBP.

Views of Women and Health Professionals on mHealth Lifestyle Interventions in Pregnancy: A Qualitative Investigation

Background

Evidence suggests that women are failing to meet guidelines for nutrition, physical activity, and weight gain during pregnancy. Interventions to promote a healthy lifestyle in pregnancy demonstrate mixed results and many are time and resource intensive. mHealth-delivered interventions offer an opportunity to provide trusted source information in a timely and cost-effective manner. Studies regarding women’s and health professionals’ views of mHealth in antenatal care are limited.

Objective

This study aimed to explore women’s and health professionals’ views regarding mHealth information sources and interventions to assist women to eat well, be physically active, and gain healthy amounts of weight in pregnancy.

Methods

A descriptive qualitative research approach employed focus groups and in-depth interviews with 15 pregnant or postpartum women and 12 in-depth interviews with health professionals including two from each category: obstetricians, general practitioners, midwives, dietitians, physiotherapists, and community pharmacists. All interviews were transcribed verbatim and thematically analyzed.

Results

Women uniformly embraced the concept of mHealth information sources and interventions in antenatal care and saw them as central to information acquisition and ideally incorporated into future antenatal care processes. Health professionals exhibited varied views perceiving mHealth as an inevitable, often parallel, service rather than one integrated into the care model. Four key themes emerged: engagement, risk perception, responsibility, and functionality. Women saw their ability to access mHealth elements as a way to self-manage or control information acquisition that was unavailable in traditional care models and information sources. The emergence of technology was perceived by some health professionals to have shifted control of information from trusted sources, such as health professionals and health organizations, to nontrusted sources. Some health professionals were concerned about the medicolegal risks of mHealth (incorrect or harmful information and privacy concerns), while others acknowledged that mHealth was feasible if inherent risks were addressed. Across both groups, there was uncertainty as to who should be responsible for ensuring high-quality mHealth. The absence of a key pregnancy or women’s advocacy group, lack of health funds for technologies, and the perceived inability of maternity hospitals to embrace technology were seen to be key barriers to provision. Women consistently identified the functionality of mHealth as adding value to antenatal care models. For some health professionals, lack of familiarity with and fear of mHealth limited their engagement with and comprehension of the capacity of new technologies to support antenatal care.

Conclusions

Women exhibited positive views regarding mHealth for the promotion of a healthy lifestyle in antenatal care. Conversely, health professionals expressed a much wider variation in attitudes and were more able to identify potential risks and barriers to development and implementation. This study contributes to the understanding of the opportunities and challenges in developing mHealth lifestyle interventions in antenatal care.

From maternity paper hand-held records to electronic health records: what do women tell us about their use?

The paper hand-held record (PHR) has been used extensively in general practice (GP) shared care management of pregnant women, and recently, the first Mater Shared Electronic Health Record (MSEHR) was introduced. The aim of this qualitative study was to examine women's experiences using the records and the contribution of the records to integrate care. At the 36-week antenatal visit in a maternity tertiary centre clinic, women were identified as a user of either the PHR or the MSEHR and organised into Phase 1 and Phase 2 studies respectively. Fifteen women were interviewed in Phase 1 and 12 women in Phase 2. Semi-structured interviews were used for data collection, and analysed using qualitative content analysis. Four main themes were identified: (1) purpose of the record, (2) perceptions of the record; (3) content of the record, and (4) sharing the record. Findings indicate that the PHR is a well-liked maternity tool. The findings also indicate there is under-usage of the MSEHR due to health-care providers failing to follow up and discuss the option of using the electronic health record option or if a woman has completed the log-in process. This paper adds to an already favourable body of knowledge about the use of the PHR. It is recommended that continued implementation of the MSEHR be undertaken to facilitate its use.

Gestational weight gain information: seeking and sources among pregnant women

Background

Promoting healthy gestational weight gain (GWG) is important for preventing obstetric and perinatal morbidity, along with obesity in both mother and child. Provision of GWG guidelines by health professionals predicts women meeting GWG guidelines. Research concerning women’s GWG information sources is limited. This study assessed pregnant women’s sources of GWG information and how, where and which women seek GWG information.

Methods

Consecutive women (n = 1032) received a mailed questionnaire after their first antenatal visit to a public maternity hospital in Melbourne, Australia. Recalled provision of GWG guidelines by doctors and midwives, recalled provided GWG goals, and the obtaining of GWG information and information sources were assessed.

Results

Participants (n = 368; 35.7 % response) averaged 32.5 years of age and 20.8 weeks gestation, with 33.7 % speaking a language other than English. One in ten women recalled receiving GWG guidelines from doctors or midwives, of which half were consistent with Institute of Medicine guidelines. More than half the women (55.4 %) had actively sought GWG information. Nulliparous (OR 7.07, 95 % CI = 3.91–12.81) and obese (OR 1.96, 95 % CI = 1.05–3.65) women were more likely to seek information. Underweight (OR 0.29, 95 % CI = 0.09–0.97) women and those working part time (OR 0.52, 95 % CI = 0.28–0.97) were less likely to seek information. Most frequently reported GWG sources included the internet (82.7 %), books (55.4 %) and friends (51.5 %). The single most important sources were identified as the internet (32.8 %), general practitioners (16.9 %) and books (14.9 %).

Conclusion

More than half of women were seeking GWG guidance and were more likely to consult non-clinician sources. The small numbers given GWG targets, and the dominance of non-clinical information sources, reinforces that an important opportunity to provide evidence based advice and guidance in the antenatal care setting is currently being missed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0600-6) contains supplementary material, which is available to authorized users.

Experiences of using the Theoretical Domains Framework across diverse clinical environments: a qualitative study

Background

The Theoretical Domains Framework (TDF) is an integrative framework developed from a synthesis of psychological theories as a vehicle to help apply theoretical approaches to interventions aimed at behavior change.

Purpose

This study explores experiences of TDF use by professionals from multiple disciplines across diverse clinical settings.

Methods

Mixed methods were used to examine experiences, attitudes, and perspectives of health professionals in using the TDF in health care implementation projects. Individual interviews were conducted with ten health care professionals from six disciplines who used the TDF in implementation projects. Deductive content and thematic analysis were used.

Results

Three main themes and associated subthemes were identified including: 1) reasons for use of the TDF (increased confidence, broader perspective, and theoretical underpinnings); 2) challenges using the TDF (time and resources, operationalization of the TDF) and; 3) future use of the TDF.

Conclusion

The TDF provided a useful, flexible framework for a diverse group of health professionals working across different clinical settings for the assessment of barriers and targeting resources to influence behavior change for implementation projects. The development of practical tools and training or support is likely to aid the utility of TDF.

Mapping allied health evidence-based practice: providing a basis for organisational realignment

Objective Ahead of the convergence of two major paediatric services, we examined evidence-based practice (EBP) self-efficacy, outcome expectancy, knowledge and use among allied health (AH) staff in two major Queensland (Qld) paediatric services. This was to determine whether any differences existed based on organisational affiliation, profession and any previous training to inform a strategy to enhance AH EBP within the new organisational setting. Methods All AH staff from the two Brisbane (Qld) tertiary paediatric hospitals were invited to participate in the survey. Using a cross-sectional design, EBP self-efficacy, outcome expectancy, knowledge and use, as well as previous EBP training, were assessed with an online survey. Background demographic information obtained included professional discipline and hospital. Results One hundred and thirty-eight health practitioners completed the survey (37% response rate). Most practitioners had accessed EBP training. Mean scores for EBP attitudes (self-efficacy and outcome expectancy) and knowledge were higher than for EBP use scores. Greater variation was observed across professional disciplines than organisations. Training impacted positively on EBP measures but explained a small proportion of total variance in regression models. Conclusions The results underscore the need to provide organisational supports to AH staff for EBP implementation. Strategies other than training are required to maximally enhance EBP attitudes. The new organisational structure provides an opportunity for this cultural shift to occur. What is known about the topic? Factors affecting the EBP capabilities of AH professionals are complex and are associated with institutional culture and barriers, personal self-belief and individual experience and ability, and can exist at clinician, team and organisational levels. What does this paper add? The data from the present study confirm the emerging literature examining various AH professional groups’ EBP behaviours and ratings with a large and diverse cohort from a variety of backgrounds and across organisations. Respondents possessed a positive attitude towards EBP and moderate EBP knowledge, with these scores exceeding EBP use scores. Organisational affiliation had little impact on EBP measures. What are the implications for practitioners? Although the results of the present study highlight the importance of training in literature searching, EBP and research design and/or analysis, the findings also indicated that strategies other than training are required to maximally enhance EBP attitudes and use by AH staff. To harness the positive approach AH staff have to EBP, strategies such as incorporation of EBP principles and plans in departmental meetings and strategic reviews, as well as strengthening organisational governance in relation to EBP and research, must be developed within the new organisational structure and context; a powerful, but often overlooked, enabler of EBP.

Sharing of clinical data in a maternity setting: how do paper hand-held records and electronic health records compare for completeness?

Background

Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR.

Methods

We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records.

Results

Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording.

Conclusion

This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0650-x) contains supplementary material, which is available to authorized users.

Primary care of women after gestational diabetes mellitus: mapping the evidence-practice gap

OBJECTIVE

To determine the extent to which preventive activities, including the ordering of an oral glucose tolerance test (OGTT) between 6 and 12 weeks of birth, are integrated into women's primary care postpartum visits after a gestational diabetes mellitus (GDM)-affected pregnancy.

DESIGN AND SETTING

Prospective survey and retrospective chart audit of general practices that provide maternity shared care in south-east Queensland, July 2011 to June 2012.

PARTICIPANTS

General practitioners (n = 38) and medical records of women to whom they provided care (n = 43 women).

MAIN OUTCOME MEASURES

GPs' awareness and knowledge of GDM guidelines and delivery of postpartum preventive care.

RESULTS

The response rate for the survey/chart audit was 47%. All respondents recommended an OGTT between 6 and 12 weeks; a variety of guidelines informed practice; and weight, blood pressure and infant feeding practices were regularly checked. Mental health status and diet and exercise were discussed less consistently.

CONCLUSIONS

GPs surveyed knew guidelines around the timing and type of test for women who have experienced GDM, and the audit demonstrated that this knowledge is translated into practice. Adherence to preventive screening and advice was less consistent. This problem may exist due to the absence of a systems approach to care, resulting in a lost opportunity to systematically reduce the incidence of type 2 diabetes and promote the wellbeing of women and their infants.

Mapping of allied health service capacity for maternity and neonatal services in the southern Queensland health service district

OBJECTIVE

Allied health professionals (AHPs) in maternity and neonatology services are essential for quality care and outcomes, reflected in the minimum service delivery requirements in the Queensland Health clinical services capability framework (CSCF). However, allied health (AH) capacity across the Southern Queensland Health Service Districts (SQHSD) is not known. The aim of this project was to redress this knowledge gap to inform ongoing service planning and delivery.

METHODS

Maternity and neonatal AH clinicians in all birthing facilities in SQHSD were surveyed between October and December 2011 to investigate AHP staffing, practices and models of care. The professions surveyed included dietitians, occupational therapists, physiotherapists, psychologists, social workers and speech pathologists. Results were grouped per question, with stratification by CSCF and/or profession.

RESULTS

Fifty-five valid surveys from the 16 facilities were received. All professions were represented. Gaps in maternity AH services were identified. Awareness and use of evidence-based practices were more likely to be reported where higher full-time equivalents (FTE) were allocated.

CONCLUSION

Very low staffing levels have been recorded in all Maternity and Neonatology Services AHPs in the SQHSD. Gaps exist between actual and recommended CSCF staffing standards across all levels and professions. The results indicate that profession-specific support networks for AHPs have positive effects in the spreading of information, and continued promotion, support and involvement in these profession-specific networks is suggested for all facilities.

In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review

BACKGROUND

The paper hand-held record (PHR) has been widely used as a tool to facilitate communication between health care providers and a pregnant woman. Since its inception in the 1950s, it has been described as a successful initiative, evolving to meet the needs of communities and their providers. Increasingly, the electronic health record (EHR) has dominated the healthcare arena and the maternity general practice shared-care arrangement seems to have adopted this initiative. A systematic review was conducted to determine perspectives of the PHR and the EHR with regards to data completeness; experiences of users and integration of care between women and health care providers.

METHOD

A literature search was conducted that included papers from 1985 to 2012. Studies were chosen if they fulfilled the inclusion criteria, reporting on: data completeness; experiences of users and integration of care between women and health care providers. Papers were extracted by one reviewer in consultation with two reviewers with expertise in maternity e-health and independently assessed for quality.

RESULTS

A total of 43 papers were identified for the review, from an initial 6,816 potentially relevant publications. No papers were found that reported on data completeness in a maternity PHR or a maternity EHR, in a shared-care setting. Women described the PHR as important to their antenatal care and had a generally positive perception of using an EHR. Hospital clinicians reported generally positive experiences using a PHR, while both positive and negative impressions were found using an EHR. The few papers describing the use of the PHR and EHR by community clinicians were also divergent and inconclusive with regards to their experiences. In a general practice shared-care model, the PHR is a valuable tool for integration between the woman and the health care provider. While the EHR is an ideal initiative in the maternity setting, facilitating referrals and communication, there are issues of fragmentation and continued paper use.

CONCLUSIONS

There was a surprising gap in knowledge surrounding data completeness on maternity PHRs or EHRs. There is also a paucity of available impressions from community clinicians using both forms of the records.

Trial for Reducing Weight Retention in New Mums: a randomised controlled trial evaluating a low intensity, postpartum weight management programme

BACKGROUND

Failure to return to pregnancy weight by 6 months postpartum is associated with long-term obesity, as well as adverse health outcomes. This research evaluated a postpartum weight management programme for women with a body mass index (BMI) > 25 kg m(-2) that combined behaviour change principles and a low-intensity delivery format with postpartum nutrition information.

METHODS

Women were randomised at 24-28 weeks to control (supported care; SC) or intervention (enhanced care; EC) groups, stratified by BMI cohort. At 36 weeks of gestation, SC women received a 'nutrition for breastfeeding' resource and EC women received a nutrition assessment and goal-setting session about post-natal nutrition, plus a 6-month correspondence intervention requiring return of self-monitoring sheets. Weight change, anthropometry, diet, physical activity, breastfeeding, fasting glucose and insulin measures were assessed at 6 weeks and 6 months postpartum.

RESULTS

Seventy-seven percent (40 EC and 41 SC) of the 105 women approached were recruited; 36 EC and 35 SC women received a programme and 66.7% and 48.6% completed the study, respectively. No significant differences were observed between any outcomes. Median [interquartile range (IQR)] weight change was EC: -1.1 (9.5) kg versus SC: -1.1 (7.5) kg (6 weeks to 6 months) and EC: +1.0 (8.7) kg versus SC: +2.3 (9) kg (prepregnancy to 6 months). Intervention women breastfed for half a month longer than control women (180 versus 164 days; P = 0.10). An average of 2.3 out of six activity sheets per participant was returned.

CONCLUSIONS

Despite low intervention engagement, the high retention rate suggests this remains an area of interest to women. Future strategies must facilitate women's engagement, be individually tailored, and include features that support behaviour change to decrease women's risk of chronic health issues.

Overweight and obesity in pregnancy: the evidence-practice gap in staff knowledge, attitudes and practices

BACKGROUND

Statewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. However, dissemination of guidelines alone do not change practice.

AIM

To systematically assess evidence-practice gap in the multidisciplinary management of overweight and obesity (ow/ob) in pregnancy to inform an intervention to facilitate translating obesity guidelines into practice in a tertiary maternity service.

MATERIALS AND METHODS

An online survey, available over a three-week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff. Outcomes of interest included a 15-point guideline adherence score, knowledge of guideline content, advice given, knowledge of obesity-pregnancy-related complications, previous training and referral patterns.

RESULTS

Eighty-four staff completed surveys (57% response rate). Widespread discordance with the guideline was noted. The majority (88.1%) reported overweight/obesity (ow/ob) as an important/very important general obstetric issue, most correctly identified associated complications. However, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. Compliance with referral recommendations varied; 20% of staff considered referral 'was not their job'.

CONCLUSIONS

Staff are aware of negative outcomes associated with maternal ow/ob, although few are fully compliant with referral guidelines or provide advice in line with recommendations. These findings will be categorised using implementation of science methodological frameworks, and effective behaviour change interventions will be constructed to facilitate translation of this important guideline into practice.

Maternal overweight and obesity: a survey of clinicians' characteristics and attitudes, and their responses to their pregnant clients

Background

Statewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. Our aim was to assess staff knowledge about, adherence to, and characteristics that influence delivery of care according to these Guidelines.

Methods

An online survey, available over a three week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff working in a tertiary maternity hospital. Outcomes included knowledge of guideline content, advice given, knowledge of obesity pregnancy-related complications, previous training, referral patterns, and staff characteristics, including lifestyle habits, body satisfaction, and Body Mass Index (BMI).

Results

Seventy-three staff completed surveys (59.6% response rate). Mean self-reported BMI was 24.2 ± 4.1 kg/m² (17.9-36.4); 28.5% of staff were overweight (19%) or obese (9.5%), and 27.4% were underweight. However, 28.6%, 2.4%, and 1.2% ‘self-classified’ themselves as overweight, obese, and underweight, respectively. Almost 40% were dissatisfied/extremely dissatisfied with their weight. While the majority reported overweight/obesity (ow/ob) as an important/very important general obstetric issue and most correctly identified associated perinatal complications, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. A quarter indicated they did not provide women with gestational weight gain (GWG) advice relative to BMI category. Staff identified they would like more training in the area of supporting women to achieve and understand the need for healthy GWG. Staff role was significantly associated with guideline adherence (p=0.03) and association with BMI category approached significance (p=0.07). An association was observed between staff’s BMI and their belief in the influence of their advice on women’s GWG (p=0.013) and weight satisfaction and belief in women having the resources to make the changes they recommend (p=0.003).

Conclusions

Whilst lack of guideline knowledge provides a barrier to best-practice care, our findings suggest an interplay between staff confidence and personal characteristics in delivering such care which deserves recognition in staff education and training, and service development programs and future research.