Evaluating maternal health capacity building in rural and underserved areas: a research protocol.

INTRODUCTION: The US is currently experiencing a maternal health crisis. Maternal morbidity and mortality in the US are higher than in other developed nations and continue to rise. Infant mortality, likewise, is higher in the US than in other developed nations. Limited availability of maternal health services, particularly in rural areas, contributes to this crisis. Maternal health outcomes are poorer, and maternal care workforce shortages are more severe in rural areas of the US. In rural areas where obstetric specialists are rare, many patients rely on family medicine physicians for maternity care. However, the number of family medicine physicians who provide maternal care services is decreasing, aggravating shortages. Calls have been made to build maternal care capacity in rural areas. The role family medicine will play in addressing the maternal health crisis is not clear. Maternal care shortages are complex issues resulting from multiple factors; likewise, efforts to build maternal health capacity are challenging and require multifaceted approaches. METHODS: With funding from the Health Resources and Services Administration (HRSA), the University of Utah seeks to address the shortage of quality maternity care in rural and underserved areas of Utah by strengthening partnerships, enhancing maternal care training of family medicine residents and obstetrics fellows, and improving the transition from training to rural practice for residents and fellows. This protocol describes the evaluation of the HRSA-funded project. The evaluation includes three components. Component 1 consists of qualitative interviews with a diverse group of maternal health providers, administrators, educators and academics, patients, and others. Interviews will be analyzed using qualitative content analysis. Component 2 is a survey of family medicine residents and obstetrics fellows, which aims to increase understanding of the factors and circumstances influencing intention to practice in rural or underserved areas and to provide maternal health services. Component 3 involves surveying fellowship alumni and tracking graduates to assess effectiveness of training programs in producing physicians who provide maternal health services in rural and underserved areas. Surveys will be analyzed with descriptive statistics including means, frequencies, and cross-tabulations. If sample size and participation provide sufficient power, statistical tests will be included in analyses. RESULTS: Evaluation results will help to fill an important gap in research literature concerning outcomes of projects and initiatives designed to build maternal care capacity in rural areas of the US. In addition, results will provide valuable information regarding effective practices for building capacity, which can be adopted elsewhere to address maternal care shortages. Finally, results will help to define the role of family medicine in addressing the maternal health crisis. Amid maternal care shortages, fewer and fewer family medicine physicians are providing maternal care in their practice. Evaluation results will clarify the role of training and preparation of family medicine residents in addressing workforce shortages. CONCLUSION: This evaluation will provide important contributions, but additional research is needed, including research protocols and studies of project outcomes, to understand how best to resolve the maternal care crisis in the US.

Component analysis of adherence in a family intervention.

PURPOSE: Most studies of adherence use a single global measure to examine the relation of adherence to outcomes. These studies inform us about effects of overall implementation but not about importance of specific program elements. Previous research on the Strengthening Families Program 10-14 has shown that outcomes were unrelated to global adherence. The purpose of the present study was to determine whether adherence to specific components of SFP was related to outcomes, even though global adherence was not. DESIGN/METHODOLOGY/APPROACH: The authors micro-coded data from an observational study of 11 instances of SFP (N = 47 facilitators, 151 participants) into specific process and content components. Using multilevel analysis, they examined the relation of each component to program outcomes, accounting for individual- and program-level variables. FINDINGS: Most associations of adherence with outcome were negligible for European-Americans but significant for minority participants. RESEARCH LIMITATIONS/IMPLICATIONS: Global assessments of implementation are insufficient for complex, multi-component prevention programs and may obscure relations of implementation to outcomes. Additionally, program components may function differently based on participant characteristics. PRACTICAL IMPLICATIONS: Facilitators would benefit from understanding the function of individual program components, particularly when programs are delivered to diverse audiences. Program developers should provide detailed logic models of program theory to guide facilitators' decisions about adaptation. ORIGINALITY/VALUE: This is one of only a few studies to examine the relation of adherence to specific intervention components to outcomes in a real-world setting. Results show the utility of component analysis and the importance of considering individual characteristics for implementation assessment.