Exploring the world of food with families: perspectives of low-income families on factors influencing their food choices.

OBJECTIVE: The aim of this study was to investigate the social and environmental factors involved in the food decision-making processes of families living on lower incomes on the Island of Ireland. DESIGN: A qualitative design was employed for this study, using photovoice and creative mapping methods. Parents were requested to take photos and draw maps of their food environments. Interviews were then conducted with parents, using the materials produced by parents as a cue to discuss their food environments, influences and decision-making processes around food choices. SETTING: The participants were interviewed online via Microsoft Teams. PARTICIPANTS: The participants were parents or guardians of children between the ages of 2 and 18 who self-defined as 'living on a tight budget'. RESULTS: Twenty-eight participants were recruited and interviewed for this study, including twelve parents in Northern Ireland and sixteen in the Republic of Ireland. The findings were mapped on to Bronfenbrenner's Ecological Systems Theory and showed that multiple, overlapping and intersecting factors at the individual, micro-, meso-, exo-, macro- and chrono-system were implicated in family food choices. Upstream factors in particular, including structural, policy and commercial determinants, appear to be significant drivers of behaviour. CONCLUSIONS: While the findings suggest that a complex range of factors are involved in family food choices, it is clear that policy measures and regulations are needed to stave off the impacts of rising social inequality and food poverty. Health promoters should strive to find non-stigmatising interventions to bridge the nutritional divide experienced by lower-income families.

Bridging the gap between pregnancy loss research and policy and practice: insights from a qualitative survey with knowledge users.

BACKGROUND: The loss of a pregnancy or the death of baby around the time of their birth can have profound impacts on parents, families and staff involved. There is much opportunity to enhance the systematic uptake of evidence-based interventions to enhance service provision, lived experiences and outcomes. Challenges exist to translating pregnancy loss research evidence into policy and practice, however. Pregnancy loss remains a neglected area of research and resourcing and is steeped in stigma. While barriers and facilitators to the use of research evidence by decision-makers in public health and health services are well documented, we aimed to better understand the factors that influence the translation of pregnancy loss research into practice and policy. METHODS: We conducted a qualitative online survey of pregnancy loss research knowledge users in Ireland, identified through our clinical and academic networks, between January and March 2022. The survey comprised ten questions, with three closed questions, informed by the Knowledge Translation Planning Template©. Questions included who could benefit from pregnancy loss research, perceived barriers and facilitators to the use of research evidence and preferred knowledge translation strategies. We analysed data using reflexive thematic analysis. RESULTS: We included data from 46 participants in our analysis, from which we generated two central themes. The first-'End the silence; stigma and inequality around pregnancy loss to enhance awareness and understanding, public health and services and supports'-addresses issues related to the stigma, sensitivities and silence, lack of awareness and understanding, and lack of relevance or priority afforded to pregnancy loss. The second theme-'Use a range of tailored, accessible approaches to engage a large, diverse range of knowledge users'-highlights the need to use relevant, accessible, and engaging information, resources or materials in knowledge translation efforts, and a variety of tailored approaches to suit different audiences, including materials, workshops/webinars, media, knowledge brokers and champions or opinion leaders. CONCLUSIONS: Our analysis provides rich insights into the barriers and facilitators to knowledge translation in the field of pregnancy loss research. We identified key strategies that can be used to inform knowledge translation planning in Ireland, and which have international applicability.

Methodological and practical guidance for designing and conducting online qualitative surveys in public health.

Online qualitative surveys-those surveys that prioritise qualitative questions and interpretivist values-have rich potential for researchers, particularly in new or emerging areas of public health. However, there is limited discussion about the practical development and methodological implications of such surveys, particularly for public health researchers. This poses challenges for researchers, funders, ethics committees, and peer reviewers in assessing the rigour and robustness of such research, and in deciding the appropriateness of the method for answering different research questions. Drawing and extending on the work of other researchers, as well as our own experiences of conducting online qualitative surveys with young people and adults, we describe the processes associated with developing and implementing online qualitative surveys and writing up online qualitative survey data. We provide practical examples and lessons learned about question development, the importance of rigorous piloting strategies, use of novel techniques to prompt detailed responses from participants, and decisions that are made about data preparation and interpretation. We consider reviewer comments, and some ethical considerations of this type of qualitative research for both participants and researchers. We provide a range of practical strategies to improve trustworthiness in decision-making and data interpretation-including the importance of using theory. Rigorous online qualitative surveys that are grounded in qualitative interpretivist values offer a range of unique benefits for public health researchers, knowledge users, and research participants.

Using Online Photovoice to Explore Food Decisions of Families on Low Income: Lessons Learnt During the COVID-19 Pandemic.

The method of photovoice has been previously used to effectively engage with socioeconomically disadvantaged groups and explore their eating behaviours. In this methodological article, we draw on our experiences from using photovoice through online interviews with families on low income about their food decisions. A purposive recruitment approach targeted parents of children 2-17 years old who lived on a tight budget across the island of Ireland. Participants provided demographic information and were invited to take photographs of food-related decisions and activities for 1 week during the COVID-19 lockdown. The photographs were then discussed through an online communication platform to generate qualitative data. A total of 28 parents participated in the photo-elicited interviews and shared a total of 642 photographs of factors that influenced their food decisions. Following the interviews, the researchers documented their reflections which focused on (1) participants' engagement with the online photo-elicitation and (2) practical aspects around participant consent and data safety. The participants in our study engaged well with the online photovoice method and shared a variety of photos which provided ample material to facilitate the conversations around their food environment and its impact on their food decisions. Our experiences can provide novel insights into using photovoice in a virtual environment and useful considerations around ethics and data collection for researchers who work with socioeconomically disadvantaged groups. Photo-elicited interviews offer an engaging and flexible data collection technique that can highlight issues informing future priorities of healthcare policy.

'An extra level of kind of torment': Views and experiences of recurrent miscarriage care during the initial phases of COVID-19 in Ireland-A qualitative interview study.

INTRODUCTION: Maternity services underwent much change during the COVID-19 pandemic. Research on the impact on miscarriage care and experiences during this time is sparse. Within a national evaluation of recurrent miscarriage care, we qualitatively explored stakeholder views and experiences of recurrent miscarriage services in Ireland. This study describes the impact of the COVID-19 pandemic on those experiences and perceptions of care. METHODS: People with professional and lived experience of recurrent miscarriage and service engagement were actively involved in this qualitative study from idea generation to analysis and reporting. We recruited women and men with two or more consecutive first-trimester miscarriages, and people involved in the management/delivery of recurrent miscarriage services and supports. We used purposive sampling to ensure that perspectives across disciplinary or lived experience, geographical, and health service administrative areas, were included. We conducted semi-structured interviews, virtually all due to COVID-19 restrictions, between June 2020 and February 2021. These were audio-recorded, and data were transcribed, and subsequently analyzed using reflexive thematic analysis. RESULTS: We interviewed 42 service providers and 13 women and 7 men with experience of recurrent miscarriage. We actively generated two central themes during data analysis. The first-'Disconnected'-describes how many women navigated miscarriage diagnosis and management and care in subsequent pregnancies alone; many felt that this resulted in increased trauma. At the same time, men struggled with not being present to support their partners and described feeling disconnected. The second theme highlighted 'The perceived dispensability of recurrent miscarriage services and supports'. Some service providers felt that service reduction and redeployment demonstrated a lack of value in the service. Virtual clinics facilitated access to services, but a preference for in-person care was highlighted. CONCLUSION: Our analysis provides rich insights into the significant impacts that the COVID-19 pandemic has had on the way recurrent miscarriage care is provided and experienced, with important implications for early pregnancy, miscarriage and recurrent miscarriage care. Services have undergone significant changes and, while these may be temporary, how services should be delivered in the future requires consideration, particularly given the deficits in care and care experiences highlighted prepandemic. PATIENT OR PUBLIC CONTRIBUTION: Members of the multidisciplinary RE:CURRENT Project Research Advisory Group (including four parent advocates, two of whom are co-authors on this article) were actively involved throughout the study, including the generation of topic guides and the refining of themes.

Factors that shape recurrent miscarriage care experiences: findings from a national survey.

BACKGROUND: Learning what matters to women/couples with recurrent miscarriage (RM) is essential to inform service improvement efforts and future RM care practices. Previous national and international surveys have examined inpatient stays, maternity care, and care experiences around pregnancy loss, but there is little focus on RM care. We aimed to explore the experiences of women and men who have received RM care and identify patient-centred care items linked to overall RM care experience. METHODS: Between September and November 2021, we invited people who had experienced two or more consecutive first trimester miscarriages and received care for RM in Ireland in the ten-year period prior to participate in a cross-sectional web-based national survey. The survey was purposefully designed and administered via Qualtrics. It included questions on sociodemographics, pregnancy and pregnancy loss history, investigation and treatment for RM, overall RM care experience, and patient-centred care items at various stages of the RM care pathway such as respect for patients' preferences, information and support, the environment, and involvement of partners/family. We analysed data using Stata. RESULTS: We included 139 participants (97% women, n = 135) in our analysis. Of the 135 women, 79% were aged 35-44 years (n = 106), 24% rated their overall RM care experience as poor (n = 32), 36% said the care they received was much worse than expected (n = 48), and 60% stated health care professionals in different places did not work well together (n = 81). Women were more likely to rate a good care experience if they had a healthcare professional to talk to about their worries/fears for RM investigations (RRR 6.11 [95% CI: 1.41-26.41]), received a treatment plan (n = 70) (RRR 3.71 [95% CI: 1.28-10.71]), and received answers they could understand in a subsequent pregnancy (n = 97) (RRR 8 [95% CI: 0.95-67.13]). CONCLUSIONS: While overall experience of RM care was poor, we identified areas that could potentially improve people's RM care experiences - which have international relevance - such as information provision, supportive care, communication between healthcare professionals and people with RM, and care coordination between healthcare professionals across care settings.

Recurrent miscarriage and infertility: a national service evaluation.

The appropriate clinical care of women/couples with infertility experiencing recurrent miscarriage (RM) is overlooked in international guidelines. We sought to evaluate care provision for women/couples with RM and infertility across public (19 clinics providing RM care, five fertility clinics) and private sectors (nine fertility clinics) using adapted guideline-based key performance indicators (KPIs) for RM. An online survey comprised of multiple-choice/open questions was administered via Qualtrics from November 2021 to February 2022, encompassing: (i) structure of care, (ii) investigations, (iii) treatments, (iv)counselling/supportive care and (v) outcomes. Clinical leads for pregnancy loss and fertility and clinical nurse/midwife specialists within each unit/clinic were invited to participate.The response rate 73% (24/33), varied by provider: Public RM care (18/19; 95%), 2/5 public fertility (40%); private fertility (3/9; 33%). Access to fertility expertise was limited in public RM clinics (39%). While investigations and treatments provided mostly adhered to guidelines, there was uncertainty regarding immunotherapies. Educational needs identified included fertility counselling, informative and supportive care resources. Clinical outcomes were seldom audited (2/22; 9%). Greater engagement with the private sector is required to unify care across sectors and to ensure standardised evidence-based care. Audit and outcomes reporting should be mandated. Lived experience of current care structures should inform service improvements.Impact StatementWhat is already known on this subject? There is a paucity of research into the appropriate clinical care of women/couples with infertility experiencing recurrent miscarriage, with a resulting deficit within international RM guidelines. It is known that RM care is variable and often not in line with guidance.What do the results of this study add? This study demonstrates that while care is largely in line with clinical practice guidelines, there is variation in counselling, imaging and surgical treatments offered. Areas for education identified included fertility counselling and resources for information provision and supportive care. Clinical outcomes were seldom audited.What are the implications of these findings for clinical practice and/or further research? Fertility care must expand to ensure access for women with RM and infertility. Further research exploring barriers and facilitators to the delivery of evidence-based care for women/couples with infertility and RM is required. The lived experiences of service users must inform service improvements.

How we define recurrent miscarriage matters: A qualitative exploration of the views of people with professional or lived experience.

BACKGROUND: Recurrent miscarriage (RM) affects 1%-3% of women/couples of reproductive age depending on the definition used, for example, whether 2 or ≥3 miscarriages. Stakeholders' views of how RM is defined have received limited attention to date. A definition reflects the medical evidence and values of a society at the time, and thus warrants ongoing review. AIM: We aimed to explore the views of women and men with lived experience of RM, and those involved in the delivery/management of services and supports, on how RM is and/or should be defined. METHODS: We adopted a qualitative study design, incorporating semi-structured interviews. We used purposive sampling to recruit participants in the Republic of Ireland, ensuring diverse perspectives were included. Women and men with lived experience of ≥2 consecutive first-trimester miscarriages were recruited via health professionals and social media; other participants via the research team's networks. Interviews were audio-recorded, transcribed, pseudo-anonymized and analysed using reflexive thematic analysis. FINDINGS: We conducted interviews with 42 health professionals/service providers and 13 women and 7 men with lived experience of RM (June 2020 to February 2021). We generated three interrelated themes from the data: (i) The need for a standardized definition of recurrent miscarriage-Finding a balance between research evidence, individual needs and healthcare resources, (ii) The definition is a route to finding an answer and/or validating women/couples' experience of loss and (iii) Working around the definition-Advocacy and impacts. CONCLUSION: A nuanced approach to defining RM is warranted, one which is evidence-informed recognizes the individual needs of women/couples, and considers healthcare resources. PATIENT OR PUBLIC CONTRIBUTION: Members of the multidisciplinary RE:CURRENT (REcurrent miscarriage: evaluating CURRENT services) Project Research Advisory Group (including four parent advocates, two of whom are co-authors on this article) were actively involved throughout the study, including the generation of topic guides and the refining of themes.

Outsourcing Transcription: Extending Ethical Considerations in Qualitative Research.

Research ethics considerations foreground minimising harm to participants. Whilst increasing attention is being paid to researcher vulnerabilities, little has been written about transcriptionists, who can potentially experience emotional distress and vicarious trauma. In this article, we highlight ethical considerations when outsourcing audio for transcription as part of the RE:CURRENT (REcurrent miscarriage: evaluating CURRENT services) Project. Through qualitative interviews, we explored the perspectives of those involved in the management/delivery of services, and women and men who experienced recurrent miscarriage (N = 62). We put distress protocols in place for participants, researchers and the transcriptionist, and adopted a research team approach with the professional transcriber. The transcriptionist highlighted the isolated nature of the role; how researchers often did not brief her when commissioning work, and how the personal impacts of this work were rarely considered. Researchers and ethics committees should consider ethical responsibilities to 'do no harm' when it comes to transcriptionist wellbeing.

Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review.

Recurrent miscarriage affects 1-2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored 'poor' on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

Exploring healthcare professionals' views of the acceptability of delivering interventions to promote healthy infant feeding practices within primary care: a qualitative interview study.

OBJECTIVE: Early-life nutrition plays a key role in establishing healthy lifestyles and preventing chronic disease. This study aimed to (1) explore healthcare professionals' (HCP) opinions on the acceptability of and factors influencing the delivery of interventions to promote healthy infant feeding behaviours within primary care and (2) identify proposed barriers/enablers to delivering such interventions during vaccination visits, to inform the development of a childhood obesity prevention intervention. DESIGN: A qualitative study design was employed using semi-structured telephone interviews. Data were analysed using qualitative content analysis; findings were also mapped to the Theoretical Framework of Acceptability (TFA). SETTING: Primary care in Ireland. PARTICIPANTS: Twenty-one primary care-based HCP: five practice nurses, seven general practitioners, three public health nurses, three community dietitians and three community medical officers. RESULTS: The acceptability of delivering interventions to promote healthy infant feeding within primary care is influenced by the availability of resources, HCP's roles and priorities, and factors relating to communication and relationships between HCP and parents. Proposed barriers and enablers to delivering interventions within vaccination visits include time constraints v. opportunistic access, existing relationships and trust between parents and practice nurses, and potential communication issues. Barriers/enablers mapped to TFA constructs of Affective Attitude, Perceived Effectiveness and Self-Efficacy. CONCLUSIONS: This study provides a valuable insight into HCP perspectives of delivering prevention-focused infant feeding interventions within primary care settings. While promising, factors such as coordination and clarity of HCP roles and resource allocation need to be addressed to ensure acceptability of interventions to HCP involved in delivery.

A core outcome set for trials of infant-feeding interventions to prevent childhood obesity.

BACKGROUND: Standardisation of outcomes measured and reported in trials of infant-feeding interventions to prevent childhood obesity is essential to evaluate and synthesise intervention effects. The aim of this study is to develop an infant-feeding core outcome set for use in randomised trials of infant-feeding interventions, with children ≤1 year old, to prevent childhood obesity. METHODS: Core outcome set development followed four stages: (1) systematic review of outcomes reported in the extant literature; (2) meeting with national and international stakeholders to discuss and clarify identified outcomes; (3) e-Delphi study with national and international stakeholders to prioritise outcomes; (4) meeting with national and international stakeholders to reach consensus on outcomes. Stakeholders in stages 2-4 were paediatricians, general practitioners, nurses, midwives, non-clinician researchers, parents, dieticians, nutritionists, and childcare providers. RESULTS: Twenty-six outcomes were identified for inclusion in the core outcome set. These were grouped in nine outcome domains: 'breastfeeding and formula feeding', 'introduction of solids', 'parent feeding practices and styles', 'parent knowledge and beliefs', 'practical feeding', 'food environment', 'dietary intake', 'perceptions of infant behaviour and preferences', and 'child weight'. CONCLUSIONS: The core outcome set identified in this study is the minimum that should be measured and reported in trials of infant-feeding interventions to prevent childhood obesity. This standardisation of outcomes will enable more comprehensive examination and synthesis of the effects of infant-feeding interventions to prevent childhood obesity.

Childhood fussy/picky eating behaviours: a systematic review and synthesis of qualitative studies.

Fussy/picky eating behaviours are common across childhood. Recent reviews of the fussy eating literature focus on quantitative research and do not adequately account for families' subjective experiences, perceptions and practices. This review aims to synthesise the increasing volume of qualitative work on fussy eating. A systematic search of relevant databases was carried out. Studies were included if they were qualitative, published since 2008, with a primary focus on families' experiences, perceptions and practices regarding fussy eating, food neophobia, or food refusal in children (aged one to young adult). Studies with clinical samples, or relating to children under one year were excluded. Ten studies were eligible for this review and were synthesised using meta-ethnography (developed by Noblit and Hare). This review provides a comprehensive description and definition of fussy eating behaviours. A conceptual model of the family experience of fussy eating was developed, illustrating relationships between child characteristics (including fussy eating behaviours), parent feeding beliefs, parent feeding practices, mealtime emotions and parent awareness of food preference development. Our synthesis identified two ways in which fussy eating relates to mealtime emotions (directly and via parent feeding practices) and three distinct categories of parent beliefs that relate to fussy eating (self-efficacy, attributions and beliefs about hunger regulation). The model proposes pathways which could be explored further in future qualitative and quantitative studies, and suggests that parent beliefs, emotions, and awareness should be targeted alongside parent feeding practices to increase effectiveness of interventions. The majority of studies included in this review focus on pre-school children and all report the parent perspective. Further research is required to understand the child's perspective, and experiences of fussy eating in later childhood. PROSPERO Registration: CRD42017055943.

Caught in a 'spiral'. Barriers to healthy eating and dietary health promotion needs from the perspective of unemployed young people and their service providers.

The number of young people in Europe who are not in education, employment or training (NEET) is increasing. Given that young people from disadvantaged backgrounds tend to have diets of poor nutritional quality, this exploratory study sought to understand barriers and facilitators to healthy eating and dietary health promotion needs of unemployed young people aged 16-20 years. Three focus group discussions were held with young people (n = 14). Six individual interviews and one paired interview with service providers (n = 7). Data were recorded, transcribed verbatim and thematically content analysed. Themes were then fitted to social cognitive theory (SCT). Despite understanding of the principles of healthy eating, a 'spiral' of interrelated social, economic and associated psychological problems was perceived to render food and health of little value and low priority for the young people. The story related by the young people and corroborated by the service providers was of a lack of personal and vicarious experience with food. The proliferation and proximity of fast food outlets and the high perceived cost of 'healthy' compared to 'junk' food rendered the young people low in self-efficacy and perceived control to make healthier food choices. Agency was instead expressed through consumption of junk food and drugs. Both the young people and service providers agreed that for dietary health promotion efforts to succeed, social problems needed to be addressed and agency encouraged through (individual and collective) active engagement of the young people themselves.

An examination of care received by women with recurrent miscarriage and infertility against guideline-based key performance indicators.

OBJECTIVES: International guidelines for the management of recurrent miscarriage (RM) do not provide detailed guidance for the care of women/couples with concurrent infertility. Research studies concerning the investigation and treatment of RM frequently omit this cohort. The aim of this study was to assess the care of women/couples with infertility attending a RM clinic in a large tertiary unit in the Republic of Ireland. STUDY DESIGN: We conducted an audit of women with RM and infertility attending our RM clinic from 2008 to 2020 against 110 established guideline-based key performance indicators (KPIs) for RM care, encompassing five categories: structure of care, counselling/supportive care, investigation, treatment and outcomes. Information was gathered from documentation from the RM clinic, hospital laboratory and electronic health records. RESULTS: We identified 128 women with infertility and RM. Information provision in RM clinics regarding modifiable risk factors (71 %; 91/128) and unexplained RM (53 %; 69/128) could be improved. Most women were investigated in line with KPIs, except for pelvic ultrasound (40 %; 51/128), cytogenetic analysis (27 %; 34/128) and 3D ultrasound (2 %; 2/128). Immunotherapies were seldom prescribed (<1%); however, 98 % (125/128) of women received aspirin, 48 % LMWH (62/128) and 16 % corticosteroids (21/128). Surgical interventions were uncommon (5 %; 6/128)). The subsequent pregnancy rate was 70 % (89/128), with 36 % undergoing artificial reproductive technology (32/89). The livebirth rate was 63 % (56/89); 37 % had a further pregnancy loss (33/89), of which two were second-trimester miscarriages. CONCLUSIONS: Women with RM and infertility received care largely in line with RM guideline-based KPIs. However, we identified areas for improvement, including the quality of information provision, and access to certain investigations. While guideline-based KPIs allow for internationally applicable and reproducible audit that can direct service improvements, the experiences and needs of service-users are not captured, meriting further qualitative research.

Interactions Between Nutrition Professionals and Industry: A Scoping Review.

BACKGROUND: In recent years, interactions between nutrition professionals (NPs) and the food industry, such as sponsorship arrangements, have raised concerns, particularly as these may negatively impact the trustworthiness and credibility of the nutrition profession. This study aimed to map the literature and identify knowledge gaps regarding interactions between NPs and industry. We sought to examine the nature of such interactions and NPs perspectives about these, as well as the risks and solutions. METHODS: We conducted a scoping review according to a pre-registered protocol, searching eight electronic databases and grey literature sources in March 2021 to identify documents for inclusion. Two independent reviewers screened citations for inclusion and conducted data extraction. Quantitative and qualitative syntheses were conducted. RESULTS: We identified 115 documents for analysis, published between 1980 to 2021, with a majority from the United States (n=59, 51%). Only 32% (n=37) were empirical studies. The food industry was the most frequent industry type discussed (n=91, 79%). We identified 32 types of interactions between NPs and industry, such as continuing education provided by industry and sponsorship of professional bodies and health and nutrition organizations. The financial survival of nutrition organizations and continuing education access for NPs were the most frequently cited advantages of industry-NPs interactions. On the other hand, undermining public trust, NPs credibility and public health nutrition recommendations were pointed out as risks of these interactions. Following a code of ethics, policies, or guidelines was the most frequently proposed solution for managing these interactions. CONCLUSION: Despite the increasing attention given to this issue, few empirical papers have been published to date. There is a need for more research to better and systematically document industry interactions with NPs and the impacts associated with these, as well as more research on effective management strategies. Registry Name and Number: Interactions between nutrition professionals and industry actors: A scoping review protocol. doi:10.17605/OSF.IO/Q6PUA.

Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group.

BACKGROUND: Standardised care pathways tailored to women/couples who experience recurrent miscarriage are needed; however, clinical practice is inconsistent and poorly organised. In this paper, we outline our processes and experiences of developing guideline-based key performance indicators (KPIs) for recurrent miscarriage care with a diverse stakeholder group which will be used to evaluate national services. To date, such exercises have generally only involved clinicians, with the need for greater stakeholder involvement highlighted. METHODS: Our study involved six stages: (i) identification and synthesis of recommendations for recurrent miscarriage care through a systematic review of clinical practice guidelines; (ii) a two-round modified e-Delphi survey with stakeholders to develop consensus on recommendations and outcomes; (iii) four virtual meetings to develop this consensus further; (iv) development of a list of candidate KPIs; (v) survey to achieve consensus on the final suite of KPIs and a (vi) virtual meeting to agree on the final set of KPIs. Through participatory methods, participants provided feedback on the process of KPI development. RESULTS: From an initial list of 373 recommendations and 14 outcomes, 110 indicators were prioritised for inclusion in the final suite of KPIs: (i) structure of care (n = 20); (ii) counselling and supportive care (n = 7); (iii) investigations (n = 30); treatment (n = 34); outcomes (n = 19). Participants' feedback on the process comprised three main themes: accessibility, richness in diversity, streamlining the development process. CONCLUSIONS: It is important and feasible to develop guideline-based KPIs with a diverse stakeholder group. One hundred and ten KPIs were prioritised for inclusion in a suite of guideline-based KPIs for recurrent miscarriage care. Insights into our experiences may help others undertaking similar projects, particularly those undertaken in the absence of a clinical guideline and/or involving a range of stakeholders.

Women/couples who have recurrent/repeated miscarriages should receive care that meets their needs, through agreed care pathways. This is often not the case. Key performance indicators (KPIs) are measures of specific elements of care (structures, processes and/or outcomes), which can help us to judge the quality of care given. In this paper, we describe how we worked with women and men with lived experience, doctors, nurses, managers, and others, to develop and agree on a list KPIs for recurrent miscarriage care in Ireland. We will use these to check what services are doing across the country and what could be done better. Participants filled out surveys and took part in meetings to vote on and agree on what KPIs were important to include. They also shared their views and experiences of taking part in this work. Together, we developed 110 KPIs for recurrent miscarriage care. These include measures of how care is structured, counselling and supports, investigations and treatments provided, and health-related outcomes. Participants' valued the different views that people brought to discussions and what they learned. They suggested ways that the process could be made more participant-friendly. For example, being up-front about the time it would take, explaining medical terms more, and cutting down on the number of items to be rated in surveys. It is important and possible to develop KPIs with different groups, particularly those with lived experience. Learning from our study may help others who want to do similar projects, such as develop KPIs or guidelines for care.