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How and when doula support increases confidence in women experiencing socioeconomic adversity: Findings from a realist evaluation of an Australian volunteer doula program.

ABSTRACT: How women are cared for while having a baby can have lasting effects on their lives. Women value relational care with continuity-when caregivers get to know them as individuals. Despite evidence of benefit and global policy support, few maternity care systems across the world routinely offer relational continuity. Women experiencing socioeconomic adversity have least access to good quality maternity care. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when, and why these programs work. A realist evaluation of an Australian volunteer doula program explored these questions. The program provides free social, emotional, and practical support by trained doulas during pregnancy, birth, and early parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that support increased a woman's confidence via two possible pathways-by being with her and enabling her to see her own strength and value; and by praising her, and her feeling validated as a mother. This study aimed to test the theory in realist interviews with clients, focus groups with doulas, and with routinely collected pre-post data. Seven English-speaking and six Arabic-speaking clients were interviewed, and two focus groups with a total of eight doulas were conducted, in January-February 2020. Qualitative data were analysed in relation to the hypothesised program theory. Quantitative data were analysed for differential outcomes. Formal theories of Recognition and Relational reflexivity supported explanatory understanding. The refined program theory, Recognition, explains how and when a doula's recognition of a woman, increases confidence, or not. Five context-mechanism-outcome configurations lead to five outcomes that differ by nature and longevity, including absence of felt confidence.

SUBMITTER: O'Rourke K

PROVIDER: S-EPMC9246160 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Objective The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed. Design A realist review. Data sources Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019. Eligibility criteria for selecting studies The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes. Analysis Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory. Results Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention. Conclusions With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

Project description:BACKGROUND:Women and families experiencing socioeconomic and psychosocial adversity are the least likely to access health care but most likely to benefit. For health services to effectively meet the needs of individuals experiencing adversity, research involving the health services must be truly representative. However, individuals experiencing adversity are typically excluded from or underrepresented in health services research. This paper reports on the implementation of a quality improvement approach designed to support recruitment and retention of pregnant women experiencing adversity in a longitudinal, health services randomized controlled trial ("right@home"). METHODS:right@home recruited Australian women from 10 public maternity hospitals across the states of Victoria and Tasmania who were experiencing adversity (≥2 risk factors on screening survey). Regular follow-up assessments were conducted by phone or face-to-face to child age 2 years. Research processes were designed taking heed of previous research demonstrating effective strategies for recruiting and retaining minority groups (e.g. piloting the recruitment process; recruiting via the health service providing care to the subgroup; remunerating participants); however, we were concerned that important information was missing. Therefore, once recruitment began, we conducted a continuous evaluation of the research processes, testing and implementing changes to processes or new strategies to maximize recruitment and retention (e.g. using a suite of strategies to maintain contact with families, using flexible data collection methods, obtaining consent for data linkage for future health and education data). RESULTS:right@home enrolled a large cohort of women (N = 722) experiencing high levels of adversity according to socioeconomic status and psychosocial risk factors, and achieved excellent retention (83% completion at 2 years). Most strategies appeared to increase recruitment and retention. All required additional time from the research team to develop and test, and some required extra funding, which ranged from minor (e.g. printing) to substantial (e.g. salaries, remuneration). CONCLUSIONS:By taking a quality improvement approach, supported by sufficient resourcing and flexible research processes, it is possible to recruit and retain a large cohort of women experiencing adversity who are typically missed or lost from longitudinal research.

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How and when doula support increases confidence in women experiencing socioeconomic adversity: Findings from a realist evaluation of an Australian volunteer doula program.

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