Engaging stakeholders in prioritising and addressing evidence-practice gaps in maternal health care Melanie Gibson-Helm 1, Jodie Bailie 2, Veronica Matthews 2, Alison Laycock 2, Jacqueline Boyle 1, Ross Bailie 2 1 Monash Centre for Health Research and Implementation, Monash University, Melbourne, Australia 2 Centre for Primary Health Care Systems, Menzies School of Health Research, Charles Darwin University, Brisbane, Australia Pregnancy Care and Maternal Health Provides treatment, screening, or preventive interventions to optimise health outcomes for mothers and babies. Despite substantial challenges many Aboriginal and Torres Strait Islander women attend early and regularly in pregnancy. Need to ensure all components of recommended pregnancy care are provided to reduce disparities and improve the health of women and babies. Image courtesy of Menzies School of Health Research 1
ABCD Research Program 2007-2014 Aimed to improve provision of primary care in Aboriginal and Torres Strait Islander communities. Linked health centres and stakeholders across the health system in continuous quality improvement (CQI) research. Bailie et al: BMC Health Serv Res 2010, Implement Sci 2013 Gibson-Helm et al: Med J Aust 2015, BMC Preg & Childb 2016 How to Use Large-Scale CQI Data? Local health centre CQI cycles Maternal Health Care Clinical Audits Aggregate CQI data Current status: 2012 2014 65 health centres 1091 records 58 systems assessments Trends: 2007 2014 91 health centres 4402 records 242 systems assessments Laycock et al 2016 Gaps in care across multiple health centres Share knowledge and experience of stakeholders to find relevant strategies Use of data and research findings for development and change 2
Engaging Stakeholders in identifying Priority evidence-practice gaps and strategies for improvement: The ESP Project How to facilitate interactive, wide-scale, discussion and use of aggregate CQI data to co-produce knowledge to improve the quality of primary health care? Aims of the Maternal Health ESP Project To engage stakeholders across the primary health system in using aggregate CQI data to identify: 1) evidence-practice gaps in Aboriginal and Torres Strait Islander maternal health care 2) barriers and enablers to best-practice care 3) system-wide strategies for achieving improvement Laycock et al, Front Public Health 2016 Methods Local health centre CQI cycles Maternal Health Care Clinical Audits Evidence base Current status: 2012 2014 65 health centres 1091 records 58 systems assessments Aggregate CQI data Trends: 2007 2014 91 health centres 4402 records 242 systems assessments Research evidence at different levels of the system Theoretical Domains Framework ESP cycles of stakeholder review and feedback Report and survey: CQI data & initial evidencepractice gaps (EPGs) 1. Priority EPGs? Report and survey: agreed EPGs, relevant CQI data, health centre, system & staff domains as possible barriers & enablers 2. Barriers and enablers to improving EPGs? 3. New or refined strategies to address EPGs? 3
Recruitment Snowballing recruitment strategy: 180 stakeholders Roles Midwives, doctors, Aboriginal and/or Torres Strait Islander practitioners, academics, nurses, managers, board members, allied health, CQI facilitators, policy officers and community members. Jurisdictions National, QLD, NT, WA, SA, NSW, VIC Organisations Community controlled and government health centres, government health departments, research organisations, medicare locals, general practice Areas of Strong Performance In Pregnancy Pregnancy care plans and delivery summaries Tests for maternal immunity and infection Follow-up for abnormal glucose tests and anaemia Blood pressure checks First trimester maternal weight Fundal height, foetal heart rate and movements At the Postnatal Visit Discussion of breastfeeding and contraception 4
Phase 1: Priority Evidence-Practice Gaps 33 responses: 27 individuals, 6 groups (n=112) In Pregnancy Asking about smoking and giving cessation advice (97% rated the importance as 8-10) Asking about drinking alcohol and delivering brief counselling (94%) Assessing social risk factors and appropriate referral (94%) Screening all women for emotional wellbeing and appropriate follow-up (94%) Discussion of nutrition at postnatal visit Discuss at the Postnatal Visit Smoking, Sudden Unexpected Death in Infancy, and a safe environment for the baby (91-94%) Diet and nutrition for mother and baby (94%) Phase 2: Barriers and Enablers to High-Quality Care 13 responses: 10 individuals, 3 groups (n=60) Current Barriers Systems to support: adequate staffing experienced staff to support other staff care that responds to women s needs community engagement and capacity partnering with communities Strongly committed staff who: function effectively in teams know what best-practice care is believe it benefits populations Current Enablers Support from people of influence in health centres Systems for staff development Access to best-practice guidelines and other decision supports 5
Phase 2: Strategies for Achieving Improvement Strengthen systems for training in best-practice care for alcohol use, smoking and psychosocial wellbeing. Continuity of care involving midwifes and Aboriginal and Torres Strait Islander Health Workers. Strengthen systems to support consistent care: prompts, quality activities, links to resources. Identify and share evidence-based information about effective and sustainable interventions. Enhance referral processes to support clinical decision making and link women with services. Advocating for healthy food, adequate housing and culturally appropriate local services for referral. Work with communities to co-develop health promotion projects and client education resources. Final Report Summarised findings from all phases Feedback on Draft Nine responses received Revision Final Report Key messages Full report Data supplement http://www.menzies.edu.au/icms_docs/243265_maternal_health_final_report.pdf http://www.menzies.edu.au/page/research/indigenous_health/primary_health_care_and_health_systems_research/the_esp_project/ 6
Strengths, Limitations and Next Steps Limitations Not possible to accurately measure reach or response rates Generalisability of phase two responses may be limited Strengths Uses the most comprehensive and large-scale dataset Reflects knowledge held by a range of stakeholders Next Steps Evaluation of the overall ESP Project: does it increase understanding of how to use aggregated data for decision-making? Key Messages For Researchers The findings can focus research activities on areas of importance to stakeholders. The ESP process is a theory-informed way of consulting stakeholders when face-to-face opportunities are limited. For Health Care Providers and Health Services The findings can inform health service planning: training, staffing, quality activities. The process encouraged knowledge sharing and a focus for continued discussions of strategies. For Policy The findings can influence and inform policy to improve local availability of services, housing, healthy food. 7
Acknowledgments We sincerely thank the range of employees of stakeholder organisations and individuals who have provided generous contributions to the ESP Project. We also thank Perri Hull for report preparation and dissemination. M Gibson-Helm is a NHMRC Fellow and her conference attendance is supported by Monash Centre for Health Research and Implementation. R Bailie is an ARC Fellow. The ABCD National Research Partnership is led by Menzies School of Health Research and was funded by the National Health and Medical Research Council (ID No.545267) and the Lowitja Institute. 8