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Implementing self-management: a mixed methods study of women's experiences of a postpartum hypertension intervention (SNAP-HT).

ABSTRACT: BACKGROUND:Self-management strategies are effective in a number of medical conditions; however, implementation studies have demonstrated adoption into clinical practice can be problematic. The process of implementation was explored during a pilot randomised controlled trial evaluating postpartum blood pressure self-management in women with medicated hypertensive disorders of pregnancy. METHODS:A mixed methods study using semi-structured interviews with a qualitative and a scored (quantitative) component were undertaken as part of a pilot randomised controlled trial (SNAP-HT) in postnatal women with medicated gestational hypertension or pre-eclampsia. Women were randomised to usual care or blood pressure self-management. Self-management entailed daily home blood pressure monitoring and automated medication reduction via telemonitoring. Women from both groups optionally consented to participate in audio-recorded interviews at 4 weeks and 6 months postpartum. Interview questions were developed to explore the proposed benefits of self-management and the constructs of normalisation process theory. Participants provided a score (Likert scale 1-5) for each question and were encouraged to expand upon these answers through further discussion. The interviews were transcribed and analysed using the framework approach. RESULTS:Sixty-eight women, 34 from each randomised group, completed at least one audio-recorded interview. Several overarching themes emerged from analysis of 126 interview transcripts: control; convenience; confidence, communication and knowledge; concern; constraints; and components of the intervention. In the scored component of the analysis, both groups reported feeling more in control of their condition postpartum compared to during pregnancy, more so in those self-managing at both 4 weeks and 6 months: adjusted differences 0.6 (95% confidence interval [CI] 0.2 to 1.1) and 0.7 (95% CI 0.3 to 1.2) respectively. CONCLUSIONS:Interviews and quantitative data showed that self-management enhanced women's sense of control and improved their blood pressure-related anxiety. Prior to taking part, a few women anticipated that home monitoring might increase anxiety, but stated that it had the opposite effect. Self-management was perceived as more flexible and reactive and as enabling more targeted down-titration of medication. These data provide considerable support for blood pressure self-management postpartum and reinforce the effectiveness of the intervention used in this study. TRIAL REGISTRATION:ClinicalTrials.gov: NCT02333240. Prospectively registered on 7 January 2015.

SUBMITTER: Cairns AE

PROVIDER: S-EPMC7282057 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Implementing self-management: a mixed methods study of women's experiences of a postpartum hypertension intervention (SNAP-HT).

Cairns Alexandra E AE Tucker Katherine L KL Crawford Carole C McManus Richard J RJ Powell John J

Trials 20200609 1

<h4>Background</h4>Self-management strategies are effective in a number of medical conditions; however, implementation studies have demonstrated adoption into clinical practice can be problematic. The process of implementation was explored during a pilot randomised controlled trial evaluating postpartum blood pressure self-management in women with medicated hypertensive disorders of pregnancy.<h4>Methods</h4>A mixed methods study using semi-structured interviews with a qualitative and a scored ( ...[more]

PMID: 32517785

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Project description:BackgroundA high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients' home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation.MethodsOne hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients' medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol.ResultsMean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients.ConclusionsThis mixed-methods process evaluation provided novel insights into practitioners' decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients' readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response.Trial registration( ISRCTN13790648 ). Registered 14 May 2015.

Project description:BackgroundWeight stigma is a societal phenomenon that is very prevalent in healthcare, precipitating poor patient-provider relationships, discontinuity of care, and delayed cancer screening. Little research, though, has investigated weight stigma in prenatal and postpartum healthcare. To address this gap, this study examined the prevalence and frequency of weight-stigmatizing experiences in prenatal and postpartum healthcare.Methods501 pregnant and postpartum women responded to an online survey where they reported whether they had experienced weight stigma in prenatal or postpartum healthcare and, if so, how frequently. Participants also responded to questions about how providers had treated them regarding their weight and their reactions to these experiences. A subset of participants (n = 80) also provided examples of their experiences, and these were subjected to a thematic analysis and coded for overarching themes.ResultsNearly 1 in 5 women (n = 92) reported experiencing weight stigma in healthcare settings. Percentages differed by BMI, with 28.4% of participants with pre-pregnancy obesity endorsing healthcare providers as a source of weight stigma. Experiences occurred between "less than once a month" and "a few times a month." Obstetricians were the most commonly-reported source (33.8%), followed by nurses (11.3%). Participants reported feeling judged, shamed, and guilty because of their weight during healthcare visits. Additionally, 37 participants (7.7%) reported having changed providers because of treatment regarding their weight. Many also reported that they expected to feel or had felt uncomfortable seeking help with breastfeeding from a healthcare professional. Finally, thematic analysis of the open-ended examples identified four key themes: (1) negative attitudes and unkind or disrespectful treatment from providers; (2) evaluative comments about their weight; (3) healthcare providers focusing on their high-risk status and potential negative consequences (often when birth outcomes were ultimately healthy); and (4) inappropriate or demeaning comments.ConclusionsWeight stigma may be a common experience in pregnancy and postpartum healthcare. Providers need additional training to avoid stigmatizing their patients and inadvertently undermining patient-provider relationships, quality of care, and health outcomes.

Project description:ObjectiveTo examine the experiences of women seeking more than one termination of pregnancy (TOP) within 2 years.DesignMixed methods study.SettingSix TOP services across Scotland.SampleWomen presenting for TOP between July and December 2015.MethodsDescriptive and inferential analysis of quantitative survey data, thematic analysis of qualitative interview data and integrative analysis. In quantitative analysis, multinomial logistic regression was used to compare three groups: previous TOP within 2 years, previous TOP beyond 2 years and no previous TOP.Main outcome measuresCharacteristics and experiences of women seeking TOP.ResultsOf 1662 questionnaire respondents, 14.6% (n = 242) and 19.8% (n = 329) reported previous TOP within and beyond 2 years, respectively. The previous TOP within 2 years group was significantly less likely to own their accommodation than the no previous TOP group (adjusted odds ratio [aOR] 0.34, 95% CI: 0.18-0.62) and previous TOP beyond 2 years group (aOR: 0.44, 95% CI: 0.23-0.85); and more likely to report inconsistent (aOR: 1.63, 95% CI: 1.04-2.57; aOR: 1.95, 95% CI: 1.16-3.28) and consistent (aOR: 2.13, 95% CI: 1.39-3.26; aOR: 1.71, 95% CI: 1.07-2.76) contraceptive use than the no previous TOP and previous TOP within 2 years groups, respectively. Twenty-three women from the previous TOP within 2 years group were interviewed. Qualitative and integrative analyses highlight issues relating to contraceptive challenges, intimate partner violence, life aspirations and socio-economic disadvantage.ConclusionsWomen undergoing more than one TOP within 2 years may experience particular challenges and vulnerabilities. Service provision should recognise this and move away from stigmatising discourses of 'repeat abortion'.FundingScottish Government.Tweetable abstractWomen having two or more terminations of pregnancy in 2 years may face key challenges/vulnerabilities including intimate partner violence and socio-economic disadvantage.

Project description:BACKGROUND:When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. METHODS:Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. RESULTS:Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. CONCLUSIONS:Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

Project description:BackgroundLimited access to mental health care services due to provider shortages, geographic limitations, and cost has driven the area of mobile health (mHealth) care to address these access gaps. Reports from the Cohen Veterans Network and National Council for Behavioral Health show that in states where mental health care is more accessible, 38% of people still do not receive the care they need. mHealth strategies help to provide care to individuals experiencing these barriers at lower cost and greater convenience, making mHealth a great resource to bridge the gaps.ObjectiveWe present a mixed methods study to evaluate user experiences with the mental mHealth service, Cope Notes. Specifically, we aimed to investigate the following research questions: How do users perceive the service in relation to stigma, impact of the intervention, and perceived usefulness? How do users rate the Cope Notes service and SMS text messaging along various dimensions of acceptability? What is the relationship between Cope Notes SMS text message ratings, user personality, and coping strategies? What are user perspectives of leveraging ubiquitous sensing technologies to improve delivery and provide tailored content?MethodsWe performed qualitative interviews with Cope Notes users (N=14) who have used the service for at least 30 days to evaluate their experiences and usefulness of the service. These interviews were coded by 2 raters (SLK and JL), and the interrater reliability was calculated with SPSS (IBM Corp) at 61.8%. In addition, participants completed quantitative measures, including a user experiences survey, personality inventory (Big Five Inventory-10), and coping assessment (Brief Coping Orientation to Problems Experienced).ResultsWe derived 7 themes from our qualitative interviews: Likes or Perceived Benefits, Dislikes or Limitations, Suggested Changes, Stigma or Help Seeking, Perceptions of Ubiquitous Sensing, Cultural Sensitivity, and Alternative mHealth Resources. Exploratory analyses between acceptability ratings of Cope Notes and personality factors showed statistically significant positive relationships between seeing oneself as someone who is generally trusting and acceptability items, the most significant being item 7 (I fully understood the sentiment behind Cope Notes Messages) with (rs(10)=0.82, P=.001). We also found statistically significant relationships between acceptability and Brief Coping Orientation to Problems Experienced items, with the strongest positive correlation between participants strongly endorsing coping by accepting the reality that an event has happened and acceptability item 7 (rs(8)=0.86, P=.001).ConclusionsOur study found that Cope Notes subscribers appreciate the service for reframing their mental wellness with statistically significant correlations between personality and acceptability of the service. We found that some users prefer a more personalized experience with neutral to positive reactions to a potential companion app that continuously monitors user behavior via smartphone sensors to provide just-in-time interventions when users need it most.

Project description:Minoritised ethnic perinatal women can experience judgemental and stigmatising care due to systemic racism. Discriminatory care contributes to increased risks of poor maternal and infant outcomes, including higher rates of mental ill-health. This study aimed to explore minoritised ethnic women's experiences of maternity services, including maternity care and mental health support, within a North-West England locality. Here we use an equity lens to report the findings that describe if and how women's personal, cultural, and spiritual needs were met, their experiences of discriminatory and prejudicial care, and to identify recommendations for service provision. A mixed-methods study was undertaken comprising an online survey, interviews, and community consultations. Questions explored access to and experiences of antenatal care and education; information, communication, and choice; experiences of (dis)respect and judgement; mental health needs and support; cultural/religious needs and support; and overall experiences of maternity care. Eligibility criteria were: women, 18+ years, from self-reported minoritised ethnic backgrounds, who had given birth in the previous 2 years and received maternity care in the locality. Surveys were available in seven languages and distributed via social media, mother-baby groups, and community locations. English-speaking survey participants were invited to take part in a follow-up interview. Community staff were approached to collect data on behalf of the study team. Quantitative data were analysed descriptively (n, %) and merged with qualitative data into descriptive themes. Overall, 104 women provided data; most self-identified as Asian (65.0%) or Black (10.7%) and were aged between 30-34 (32.0%) or 25-29 years (23.3%). Four descriptive themes are reported: 'accessing care' details variations and barriers in accessing maternity care; 'communication needs, and resources' describes views on adaptions and resources for specific communication needs; 'meeting religious and cultural needs' outlines how various religious and cultural needs were met by maternity providers; 'discriminatory or stigmatising care' reports on experiences of pejorative and inequitable care. An equity lens helped identify areas of discriminatory and inequitable care. Key recommendations include cultural safety training for staff; service-user engagement and co-production of research and resources, and appropriate facilities and recording systems to facilitate individualised, needs-based maternity care.

Dataset Information

Implementing self-management: a mixed methods study of women's experiences of a postpartum hypertension intervention (SNAP-HT).

Publications

Implementing self-management: a mixed methods study of women's experiences of a postpartum hypertension intervention (SNAP-HT).

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