Effect of the Growth Assessment Protocol on the DEtection of Small for GestatioNal age fetus: process evaluation from the DESiGN cluster randomised trial

BACKGROUND: Reducing the rate of stillbirth is an international priority. At least half of babies stillborn in high-income countries are small for gestational-age (SGA). The Growth Assessment Protocol (GAP), a complex antenatal intervention that aims to increase the rate of antenatal detection of SGA, was evaluated in the DESiGN type 2 hybrid effectiveness-implementation cluster randomised trial (n = 13 clusters). In this paper, we present the trial process evaluation. METHODS: A mixed-methods process evaluation was conducted. Clinical leads and frontline healthcare professionals were interviewed to inform understanding of context (implementing and standard care sites) and GAP implementation (implementing sites). Thematic analysis of interview text used the context and implementation of complex interventions framework to understand acceptability, feasibility, and the impact of context. A review of implementing cluster clinical guidelines, training and maternity records was conducted to assess fidelity, dose and reach. RESULTS: Interviews were conducted with 28 clinical leads and 27 frontline healthcare professionals across 11 sites. Staff at implementing sites generally found GAP to be acceptable but raised issues of feasibility, caused by conflicting demands on resource, and variable beliefs among clinical leaders regarding the intervention value. GAP was implemented with variable fidelity (concordance of local guidelines to GAP was high at two sites, moderate at two and low at one site), all sites achieved the target to train > 75% staff using face-to-face methods, but only one site trained > 75% staff using e-learning methods; a median of 84% (range 78–87%) of women were correctly risk stratified at the five implementing sites. Most sites achieved high scores for reach (median 94%, range 62–98% of women had a customised growth chart), but generally, low scores for dose (median 31%, range 8–53% of low-risk women and median 5%, range 0–17% of high-risk women) were monitored for SGA as recommended. CONCLUSIONS: Implementation of GAP was generally acceptable to staff but with issues of feasibility that are likely to have contributed to variation in implementation strength. Leadership and resourcing are fundamental to effective implementation of clinical service changes, even when such changes are well aligned to policy mandated service-change priorities. TRIAL REGISTRATION: Primary registry and trial identifying number: ISRCTN 67698474. Registered 02/11/16. https://doi.org/10.1186/ISRCTN67698474

Effect of the Growth Assessment Protocol on the DEtection of Small for GestatioNal age fetus: process evaluation from the DESiGN cluster randomised trial

Background Reducing the rate of stillbirth is an international priority. At least half of babies stillborn in high-income countries are small for gestational-age (SGA). The Growth Assessment Protocol (GAP), a complex antenatal intervention that aims to increase the rate of antenatal detection of SGA, was evaluated in the DESiGN type 2 hybrid effectiveness-implementation cluster randomised trial (n = 13 clusters). In this paper, we present the trial process evaluation. Methods A mixed-methods process evaluation was conducted. Clinical leads and frontline healthcare professionals were interviewed to inform understanding of context (implementing and standard care sites) and GAP implementation (implementing sites). Thematic analysis of interview text used the context and implementation of complex interventions framework to understand acceptability, feasibility, and the impact of context. A review of implementing cluster clinical guidelines, training and maternity records was conducted to assess fidelity, dose and reach. Results Interviews were conducted with 28 clinical leads and 27 frontline healthcare professionals across 11 sites. Staff at implementing sites generally found GAP to be acceptable but raised issues of feasibility, caused by conflicting demands on resource, and variable beliefs among clinical leaders regarding the intervention value. GAP was implemented with variable fidelity (concordance of local guidelines to GAP was high at two sites, moderate at two and low at one site), all sites achieved the target to train > 75% staff using face-to-face methods, but only one site trained > 75% staff using e-learning methods; a median of 84% (range 78–87%) of women were correctly risk stratified at the five implementing sites. Most sites achieved high scores for reach (median 94%, range 62–98% of women had a customised growth chart), but generally, low scores for dose (median 31%, range 8–53% of low-risk women and median 5%, range 0–17% of high-risk women) were monitored for SGA as recommended. Conclusions Implementation of GAP was generally acceptable to staff but with issues of feasibility that are likely to have contributed to variation in implementation strength. Leadership and resourcing are fundamental to effective implementation of clinical service changes, even when such changes are well aligned to policy mandated service-change priorities. Trial registration Primary registry and trial identifying number: ISRCTN 67698474. Registered 02/11/16. https://doi.org/10.1186/ISRCTN67698474

A case study about teenage pregnancy

Purpose: Teenage pregnancy is a world-wide problem and a subject of concern in both industrialised and developing countries. It is in fact a growing concern that is very commonly reported in the media. A few studies have considered teenager opinions and have looked at their point of view. This study aims to look at teenagers attitudes to health care services so as to develop better services and thus a better outcome for this group. Methods: This is a case study which looked at a specific population, pregnant teenagers and young mothers attending Ashlyns School in Newcastle-upon-Tyne. Different approaches for gathering information were used in this study. A descriptive approach, gaining general information, through observation and documentary evidence was used. A quantitative phase using a self-administered questionnaire was undertaken, and a qualitative phase using focus-group discussions with the young mothers, and semi-structured and unstructured interviews with the key-informants was also undertaken. Participant observation was also an important component of the data collection. These different approaches have enabled us to triangulate our findings. Results: Most girls studying in Ashlyns come from a poor background, and seem to repeat a family pattern of early pregnancy. Most pregnant teenagers in the study, seem to seek consistent antenatal care. Also, the majority found antenatal care very important, but they did not like the attitude of the health care providers. They described them as judgmental, patronising, and felt that they treated young mothers differently because of their age. 50% of adolescents would prefer "young mother" clinics, and 25% would like normal clinics with timetables reserved for teenagers. In all, 75% would like something different. The main reason for in delayed antenatal care comes from the late discovery of the pregnancy. 95% of schoolgirls would like to have "young mother" discussion groups. Young mothers, mainly primipara, are keen to understand more about their pregnancy and would like more information. All the girls at Ashlyns School were successful in gaining their GCSE qualifications. Conclusion: The results seem to follow the trends of other studies reported in the literature. There are important differences, however, in the degree to which subjects in this study attended antenatal care and in subjects educational achievements. These positive findings may be the result of the greater degree of support that Ashlyns School provides. Teenage mothers to be represent an especially vulnerable group at risk of marginalisation by an early pregnancy. Specific models incorporating adapted health care and education can pull this group in from the fringe of society. These young women require self-esteem and confidence to continue productive lives and to be ensure that they are good healthy mothers