Practice change intervention to improve antenatal care addressing alcohol consumption during pregnancy: a randomised stepped-wedge controlled trial.

BACKGROUND: Clinical guideline recommendations for addressing alcohol consumption during pregnancy are sub-optimally implemented and limited evidence exists to inform practice improvements. The aim of this study was to estimate the effectiveness of a practice change intervention in improving the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services. METHODS: A randomised stepped-wedge controlled trial was undertaken with all public maternity services in three sectors (one urban, two regional/rural) of a single local health district in New South Wales, Australia. All antenatal care providers were subject to a seven-month multi-strategy intervention to support the introduction of a recommended model of care. For 35 months (July 2017 - May 2020) outcome data were collected from randomly selected women post an initial, 27-28 weeks and 35-36 weeks gestation antenatal visit. Logistic regression models assessed intervention effectiveness. RESULTS: Five thousand six hundred ninety-four interviews/online questionnaires were completed by pregnant women. The intervention was effective in increasing women's reported receipt of: assessment of alcohol consumption (OR: 2.63; 95% CI: 2.26-3.05; p < 0.001), advice not to consume alcohol during pregnancy and of potential risks (OR: 2.07; 95% CI: 1.78-2.41; p < 0.001), complete care relevant to alcohol risk level (advice and referral) (OR: 2.10; 95% CI: 1.80-2.44; p < 0.001) and all guideline elements relevant to alcohol risk level (assessment, advice and referral) (OR: 2.32; 95% CI: 1.94-2.76; p < 0.001). Greater intervention effects were found at the 27-28 and 35-36 weeks gestation visits compared with the initial antenatal visit. No differences by sector were found. Almost all women (98.8%) reported that the model of care was acceptable. CONCLUSIONS: The practice change intervention improved the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services. Future research could explore the characteristics of pregnant women and maternity services associated with intervention effectiveness as well as the sustainment of care practices over time to inform the need for, and development of, further tailored practice change support. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (Registration number: ACTRN12617000882325; Registration date: 16/06/2017) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372985&isReview=true.

The impact of Healthy Conversation Skills training on health professionals' barriers to having behaviour change conversations: a pre-post survey using the Theoretical Domains Framework.

BACKGROUND: Changing people's behaviour by giving advice and instruction, as traditionally provided in healthcare consultations, is usually ineffective. Healthy Conversation Skills (HCS) training enhances health professionals' communication skills and ability to empower and motivate people in health behaviour change. Guided by the Theoretical Domains Framework (TDF), this study examined the impact of HCS training on health professional barriers to conducting behaviour change conversations in both clinical and non-clinical settings. Secondary aims were to i) identify health professionals' barriers to having behaviour change conversations, and explore the ii) effect of HCS training on health professionals' competence and attitudes to adopting HCS, iii) feasibility, acceptability and appropriateness of using HCS in their clinical and non-clinical roles, and iv) acceptability and quality of HCS training. METHODS: HCS training was conducted in October-November 2019 and February 2020. Pre-training (T1), post-training (T2) and follow-up (T3; 6-10 weeks post-training) surveys collected data on demographics and changes in competence, confidence, importance and usefulness (10-point Likert scale, where 10 = highest score) of conducting behaviour change conversations. Validated items assessing barriers to having these conversations were based on eight TDF domains. Post-training acceptability and quality of training was assessed. Data were summarised using descriptive statistics, and differences between TDF domain scores at the specific time points were analysed using Wilcoxon matched-pairs signed-rank tests. RESULTS: Sixty-four participants consented to complete surveys (97% women; 16% identified as Aboriginal), with 37 employed in clinical settings and 27 in non-clinical settings. The training improved scores for the TDF domains of skills (T1: median (interquartile range) = 4.7(3.3-5.3); T3 = 5.7(5.3-6.0), p < 0.01), belief about capabilities (T1 = 4.7(3.3-6.0); T3 = 5.7(5.0-6.0), p < 0.01), and goals (T1 = 4.3(3.7-5.0); T3 = 4.7(4.3-5.3), p < 0.01) at follow-up. Competence in using 'open discovery questions' increased post-training (T1 = 25% of responses; T2 = 96% of responses; T3 = 87% of responses, p < 0.001), as did participants' confidence for having behaviour change conversations (T1 = 6.0(4.7-7.6); T2 = 8.1(7.1-8.8), p < 0.001), including an increased confidence in having behaviour change conversations with Aboriginal clients (T1 = 5.0(2.7-6.3); T2 = 7.6(6.4-8.3), p < 0.001). CONCLUSIONS: Provision of additional support strategies to address intentions; memory, attention and decision processes; and behavioural regulation may enhance adoption and maintenance of HCS in routine practice. Wider implementation of HCS training could be an effective strategy to building capacity and support health professionals to use a person-centred, opportunistic approach to health behaviour change.

What gets measured gets noticed. Tracking surgical site infection post caesarean section through community surveillance: A post intervention study protocol.

AIM: This study aims to evaluate the effectiveness of HealthTracker, a surgical site infection surveillance system that aims to improve the notification of surgical site infection for women after giving birth by caesarean section. DESIGN: This protocol is an intervention study to evaluate the effectiveness of the surveillance system called "HealthTracker" in monitoring surgical site infections post caesarean section. METHODS: This study will use a mobile web application to automatically send a text message inviting all women who give birth to a live baby by caesarean section over six months during 2020-2021, at an Australian tertiary referral hospital. The text message invites women to complete a web-based validated Wound Healing Questionnaire. The estimated number of eligible women in six months is 700 (caesarean section rate: 34% of 4,000 births annually). INTERVENTION: the proposed "HealthTracker" surveillance system facilitates active patient-reported surgical site infection identification through an automated mobile text message linking women to an individualized online Wound Healing Questionnaire. DISCUSSION: This project aims to provide a consistent, reliable and cost effective surgical site infection surveillance tool to improve post caesarean section surgical site infection reporting, can be scaled for broader utilization and will provide valuable information to decision makers regarding surgical site infection prevention. IMPACT: Study findings will provide insights into whether HealthTracker is an efficient and cost effective platform for a systematic and consistent approach to surgical site infection surveillance that can be adopted more broadly, across the local health organization, the State and across other surgical specialty areas. This information will equip hospitals and clinicians with knowledge to better identify patient outcomes related to SSI post discharge from hospital and inform decision making related to preventative strategies, providing the necessary momentum to introduce practice change initiatives aimed at reducing surgical site infection rates. TRIAL REGISTRATION: ACTRN12620001233910.

A case for not adjusting birthweight customized standards for ethnicity: observations from a unique Australian cohort.

BACKGROUND: Low birthweight is more common in infants of indigenous (Aboriginal and/or Torres Strait Islander) than of White Australian mothers. Controversy exists on whether fetal growth is normally different in different populations. OBJECTIVE: We sought to determine the relationships of birthweight, birthweight percentiles, and smoking with perinatal outcomes in indigenous vs nonindigenous infants to determine whether the White infant growth charts could be applied to indigenous infants. STUDY DESIGN: Data were analyzed for indigenous status, maternal age and smoking, and perinatal outcomes in 45,754 singleton liveborn infants of at least 20 weeks gestation or 400 g birthweight delivered in New South Wales, Australia, between June 2010 and July 2015. RESULTS: Indigenous infants (n=6372; 14%) had a mean birthweight 67 g lower than nonindigenous infants (P<.0001; with adjustment for infant sex and maternal body mass index). Indigenous mean birthweight percentile was 4.2 units lower (P<.0001). Adjustment for maternal age, smoking, body mass index, and infant sex reduced the difference in birthweight/percentiles to nonsignificance (12 g; P=.07). CONCLUSION: Disparities exist between indigenous and non-indigenous Australian infants for birthweight, birthweight percentile, and adverse outcome rates. Adjustment for smoking and maternal age removed any significant difference in birthweights and birthweight percentiles for indigenous infants. Our data indicate that birthweight percentiles should not be adjusted for indigenous ethnicity because this normalizes disadvantage; because White and indigenous Australians have diverged for approximately 50,000 years, it is likely that the same conclusions apply to other ethnic groups. The disparities in birthweight percentiles that are associated with smoking will likely perpetuate indigenous disadvantage into the future because low birthweight is linked to the development of chronic noncommunicable disease and poorer educational attainment; similar problems may affect other indigenous populations.

Evaluating a train-the-trainer model for scaling-up Healthy Conversation Skills training: A pre-post survey using the Theoretical Domains Framework.

OBJECTIVES: Healthy Conversation Skills (HCS) training is an established method of upskilling health professionals in person-centred behaviour change communication. A Train-the-Trainer (TtT) model was adopted to scale-up delivery of HCS training. This study examined the impact of the TtT course on new Trainers' perceived barriers and enablers to delivering HCS training using the Theoretical Domains Framework (TDF). METHODS: The TtT course was delivered in 2019-2020. Pre-training (T1) and post-training (T2) surveys collected data on barriers and enablers to delivering HCS training based on 10 TDF domains. Data were summarised using descriptive statistics, and differences between pre- and post-training scores analysed using paired t-tests. RESULTS: Forty-six trainees participated, including 43 women and 10 Aboriginal people. Scores for nine domains increased post-training, including knowledge, skills, social and professional role/identity, beliefs about capabilities, intentions, goals, environmental context and resources, social influences, and behavioural regulation. Knowledge, beliefs about consequences and intentions were no longer barriers to delivering HCS training after participating in the TtT course. CONCLUSIONS: The TtT model supports new Trainers by addressing barriers to delivering HCS training. PRACTICE IMPLICATIONS: The HCS TtT model builds healthcare workforce capacity for person-centred approaches to behaviour change. The findings facilitate the refinement of the TtT course.

An implementation intervention to increase the routine provision of antenatal care addressing gestational weight gain: study protocol for a stepped-wedge cluster trial.

BACKGROUND: Weight gain during pregnancy that is outside of recommended levels is associated with a range of adverse outcomes for the mother and child, including gestational diabetes, pre-eclampsia, preterm birth, and obesity. Internationally, 60-80% of pregnant women report gaining weight outside of recommended levels. While guideline recommendations and RCT evidence support the provision of antenatal care that supports healthy gestational weight gain, less than 10% of health professionals routinely weigh pregnant women; discuss weight gain, diet, and physical activity; and provide a referral for additional support. This study aims to determine the effectiveness of an implementation intervention in increasing the provision of recommended gestational weight gain care by maternity services. METHODS: A stepped-wedge controlled trial, with a staggered implementation intervention, will be conducted across maternity services in three health sectors in New South Wales, Australia. The implementation intervention will consist of evidence-based, locally-tailored strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training, and monitoring and feedback. Primary outcome measures will be the proportion of women who report receiving (i) assessment of gestational weight gain; (ii) advice on gestational weight gain, dietary intake, and physical activity; and (iii) offer of referral to a telephone coaching service or local dietetics service. Measurement of outcomes will occur via telephone interviews with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost, cost-consequence, cost-effectiveness, and budget impact of the implementation intervention. Receipt of all care elements, acceptance of referral, weight gain during pregnancy, diet quality, and physical activity will be measured as secondary outcomes. Process measures including acceptability, adoption, fidelity, and reach will be reported. DISCUSSION: This will be the first controlled trial to evaluate the effectiveness of a implementation intervention in improving antenatal care that addresses gestational weight gain. The findings will inform decision-making by maternity services and policy agencies and, if the intervention is demonstrated to be effective, could be applied at scale to benefit the health of women and children across Australia and internationally. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 . Registered on 22 January 2021.

Are antenatal interventions effective in improving multiple health behaviours among pregnant women? A systematic review protocol.

BACKGROUND: Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women. METHODS: Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form. DISCUSSION: The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018095315.

Implementation strategies to improve preconception and antenatal care for tobacco smoking, alcohol consumption and weight management: a systematic review protocol.

BACKGROUND: Despite existing best practice care recommendations for addressing tobacco smoking, alcohol consumption and weight management in preconception and antenatal care, such recommendations are often not implemented into routine practice. Effective strategies that target known barriers to implementation are key to reducing this evidence to practice gap. The aim of this review is to synthesise the evidence on the effectiveness of implementation strategies in improving the provision of preconception and antenatal care for these modifiable risk factors. METHODS: Randomised and non-randomised study designs will be eligible for inclusion if they have a parallel control group. We will include studies that either compare an implementation strategy to usual practice or compare two or more strategies. Participants may include any health service providing preconception or antenatal care to women and/or the health professionals working within such a service. The primary outcome will be any measure of the effectiveness of implementation strategies to improve preconception and/or antenatal care for tobacco smoking, alcohol consumption and/or weight management (including care to improve nutrition and/or physical activity). Secondary outcomes will include the effect of the implementation strategy on women's modifiable risk factors, estimates of absolute costs or cost-effectiveness and any reported unintentional consequences. Eligible studies will be identified via searching Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, ProQuest Dissertations and Theses and other sources (e.g. contacting experts in the field). Study selection, data extraction and risk of bias will be assessed independently by two review authors and differences resolved by a third reviewer. If data permits, we will conduct fixed-effects or random-effects meta-analysis where appropriate. If studies do not report the same outcome or there is significant heterogeneity, results will be summarised narratively. DISCUSSION: This review will identify which implementation strategies are effective in improving the routine provision of preconception and antenatal care for tobacco smoking, alcohol consumption and weight management. Such a review will be of interest to service providers, policy makers and implementation researchers seeking to improve women's modifiable risk factors in preconception and antenatal care settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019131691.

A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial.

BACKGROUND: Despite clinical guideline recommendations, implementation of antenatal care addressing alcohol consumption by pregnant women is limited. Implementation strategies addressing barriers to such care may be effective in increasing care provision. The aim of this study is to examine the effectiveness, cost and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women. METHODS: The study will be a randomised, stepped-wedge controlled trial conducted in three sectors in a health district in New South Wales, Australia. Stepped implementation of a practice change intervention will be delivered to sectors in a random order to support the introduction of a model of care for addressing alcohol consumption by pregnant women. A staged process was undertaken to develop the implementation strategies, which comprise of: leadership support, local clinical practice guidelines, electronic prompts and reminders, opinion leaders, academic detailing (audit and feedback), educational meetings and educational materials, and performance monitoring. Repeated cross-sectional outcome data will be gathered weekly across all sectors for the study duration. The primary outcome measures are the proportion of antenatal appointments at 'booking in', 27-28 weeks gestation and 35-36 weeks gestation for which women report (1) being assessed for alcohol consumption, (2) being provided with brief advice related to alcohol consumption during pregnancy, (3) receiving relevant care for addressing alcohol consumption during pregnancy, and (4) being assessed for alcohol consumption and receiving relevant care. Data on resources expended during intervention development and implementation will be collected. The proportion of women who report consuming alcohol since knowing they were pregnant will be measured as a secondary outcome. DISCUSSION: This will be the first randomised controlled trial to evaluate the effectiveness, cost and cost-effectiveness of implementation strategies in improving antenatal care that addresses alcohol consumption by pregnant women. If positive changes in clinical practice are found, this evidence will support health service adoption of implementation strategies to support improved antenatal care for this recognised risk to the health and wellbeing of the mother and child. TRIAL REGISTRATIONS: Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Documentation of preoperative counselling for female sterilisation: a complete audit cycle.

BACKGROUND: Female sterilisation is a commonly performed gynaecological procedure that attracts a disproportionate number of complaints and litigation. Documentation of the key counselling issues provides an important record of the information given to the woman prior to undergoing sterilisation. METHODS: Auditable standards were obtained from published guidelines. After the initial audit of 100 cases a proforma was introduced in an effort to improve documentation. A re-audit of 50 cases was undertaken to ascertain compliance of documentation following the introduction of the proforma. RESULTS: The proforma was used in 62% of cases and in all such cases documentation was 100% compliant with the auditable standards. Overall, documentation of standards pre- and post-proforma, respectively, was as follows (all the figures quoted are percentage values, with the range given in parentheses): 33 (24-43) vs 68 (53-80) for long-term alternatives, 94 (87-98) vs 78 (62-87) for irreversibility, 96 (90-99) vs 78 (64-88) for failure rate, 48 (38-58) vs 66 (51-79) for ectopic pregnancy risk if sterilisation fails, 39 (29-49) vs 66 (51-79) for the intended method, 67 (57-76) vs 66 (51-79) for operative risks and 37 (28-47) vs 64 (49-77) for continuing current contraception until sterilisation performed. CONCLUSIONS: Documentation of preoperative counselling for female sterilisation is often incomplete and does not comply with published recommendations. The introduction of a proforma resulted in a mixture of both improvement and deterioration of documentation. When the proforma was used, compliance with recommendations was 100%.