Facilitators and barriers in the implementation and adoption of Patient Reported Outcomes Measurements in daily practice.

OBJECTIVES: At the Erasmus MC, Patient Reported Outcome Measures (PROMs) are implemented on a hospital-wide scale. However, less than half of the patients and healthcare professionals (HCP) utilize these PROMs. Therefore, this study aimed to investigate facilitators and barriers for adoption of PROMs to develop guidance around implementation. METHODS: A mixed-methods study with a combination of interviews and focus groups, and questionnaires was conducted, involving patients, both PROM non-responders and PROM responders, HCPs, and medicine students and nurse specialists in training (hereafter 'students'). (Group)interview transcripts were subjected to thematic content analysis. Subsequently, questionnaires were developed and presented to all stakeholders to validate the findings. Last, identified themes and implementation recommendations were presented in a final questionnaire to the Value Based Healthcare Erasmus MC expert group to prioritize findings. RESULTS: Interviews were conducted with 15 patients, 14 HCPs and 4 students, and 2 focus groups with 5 students. The questionnaire was completed by 370/999 responders (37.0%), 173/1395 non-responders (12.5%), 44/194 HCPs (22.7%) and 40 students were reached via an open link. The identified facilitators and barriers were grouped into four overarching themes; training on PROMs at different levels in the education of (future) HCPS, motivate and reduce the burden for the HCP, implement generic and disease-specific PROMs simultaneously and motivate, activate and reduce the patient burden. CONCLUSIONS: Providing end-users with digital tools, implementation support and a clear hospital-wide vision are important, yet this does not guarantee successful adoption of PROMs. Successful adoption necessitates ongoing efforts to engage, motivate and train end-users.

Factors involved in the decision to decline prenatal screening with noninvasive prenatal testing (NIPT).

OBJECTIVE: To investigate factors involved in the decision to decline prenatal screening with noninvasive prenatal testing (NIPT). METHOD: A questionnaire study was conducted among 219 pregnant women in the Netherlands who had declined prenatal screening with NIPT (TRIDENT-2 study). Respondents were selectively recruited from three hospitals and 19 midwifery practices, primarily located in or near socioeconomically disadvantaged neighborhoods. 44.3% of the respondents were of non-Western ethnic origin and 64.4% were religious. RESULTS: Most respondents (77.2%) found the decision to decline NIPT easy to make, and 59.8% had already made the decision before information about NIPT was offered. These respondents were more often religious, multigravida, and had adequate health literacy. The main reasons to decline NIPT were "I would never terminate my pregnancy" (57.1%) and "every child is welcome" (56.2%). For 16.9% of respondents, the out-of-pocket costs (175 euros) played a role in the decision, and the women in this group were more often nonreligious, primigravida, and had inadequate health literacy. CONCLUSION: The primary factors involved in the decision to decline NIPT were related to personal values and beliefs, consistent with autonomous choice. Out-of-pocket costs of NIPT hinder equal access for some pregnant women.

An unwanted pregnancy and language proficiency level are associated with first antenatal visit after the first trimester: Results from a prospective cohort study.

OBJECTIVE: To study the association between the reasons for a 'late' first antenatal visit and the influence of several maternal determinants and practical limitations on the timing of the first antenatal visit. DESIGN: A prospective cohort study. SETTING: Southwest region of The Netherlands, mainly characterised by large urban and suburban areas. PARTICIPANTS: Women receiving information and counselling about prenatal screening between April 2010 and December 2010 were included (n = 9,268). MEASUREMENTS AND FINDINGS: Timing of first antenatal visit, categorised as: 'in time' (<12+0 weeks of gestation), 'late' (≥12-23+6 weeks of gestation) and 'very late' (≥24 weeks of gestation). An unplanned or unwanted pregnancy was the most frequently reported reason for delay of the first antenatal visit (30.7%) especially in Surinamese women (79%), and women younger than 20 years (63%) or older than 40 years (50.0%). Compared to women who timed their first antenatal visit 'in time', women with a delay in their first visit were more often younger than 20 or older than 40 years of age, high order multiparous (P ≥3), with a previous miscarriage, and had an absent Dutch language proficiency level. The latter showed the strongest association with a 'very late' first antenatal visit (OR 4.96, 95%CI 2.45-10.05). KEY CONCLUSIONS: Language proficiency level was highly associated with a delay in the timing of the first antenatal visit. When women timed their first antenatal visit late, having an unplanned or unwanted pregnancy was the most frequently reported reason for this delay. IMPLICATIONS FOR PRACTICE: Findings from this study can be used to inform and develop interventions to improve timely antenatal care use.

Social determinants of psychological wellness for children and adolescents in rural NSW.

BACKGROUND: The mental wellness of children and adolescents in rural Australia is under researched and key to understanding the long-term mental health outcomes for rural communities. This analysis used data from the Australian Rural Mental Health Study (ARMHS), particularly the parent report Strengths and Difficulties Questionnaire (SDQ) measure for children under 18 years old and their reporting parent's demographic information to compare this sample's mental wellness scores to the Australian norms and to identify what personal, family, community and rurality factors contribute to child mental wellness as pertaining to the SDQ total and subdomain scores. METHOD: Five hundred thirty-nine children from 294 families from rural NSW were included. SDQ scores for each child as well as personal factors (sex and age), family factors (employment status, household income and sense of community of responding parent), community SES (IRSAD) and rurality (ASCG) were examined. RESULTS: Children and adolescents from rural areas had poorer mental wellness when compared to a normative Australian sample. Further, personal and family factors were significant predictors of the psychological wellness of children and adolescents, while after controlling for other factors, community SES and level of rurality did not contribute significantly. CONCLUSIONS: Early intervention for children and families living in rural and remote communities is warranted particularly for low income families. There is a growing need for affordable, universal and accessible services provided in a timely way to balance the discrepancy of mental wellness scores between rural and urban communities.

Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research.

BACKGROUND: Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period. METHODS: We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background. RESULTS: From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems' responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women's needs. The 'respect for persons' domains 'autonomy', 'communication' and 'dignity' and the 'client orientation' domain 'prompt attention' were judged most negatively. CONCLUSIONS: The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women's population.

Ethnicity and Language Proficiency Differences in the Provision of and Intention to Use Prenatal Screening for Down's Syndrome and Congenital Anomalies. A Prospective, Non-selected, Register-Based Study in the Netherlands.

Objective We aimed to conduct an analysis of the associations between the information provision procedure of prenatal screening for Down's syndrome and congenital anomalies and the intention to participate in prenatal screening (PS) of ethnicity groups and Dutch language proficiency groups. Design Using a prospective web-based registration form, we asked counselors (midwives, general practitioners, nurses and gynecologists) to report whether and how they offered information about PS to pregnant women. Duration The study was conducted from 2008 to 2010. Participants We collected data on the characteristics of the women who received an information offer about PS from counselors. Measurements Measures included socio-demographic and language proficiency level (LPL) characteristics, key elements of the provision procedure of PS, and intentional participation in PS. Findings The dataset represents 37% of the total population in the study area. Women with a non-native Dutch background and/or insufficient Dutch LPL received fewer information offers about PS, faced a reduced chance of receiving counseling, and showed lower intentional participation rates for PS. Key Conclusions Women with a non-native Dutch background and/or with an insufficient LPL are underserved in the Dutch PS program. These findings present evidence indicating that the fundamental principle of the Dutch Population Screening Act, namely, equal access to PS for all pregnant women, is not being realized. Implications for Practice Therefore, the study findings are important for national and international healthcare, policy makers and governmental professionals to allow ethnic and LPL-related differences in the provision and intentional uptake of PS.

Inequalities in uptake of prenatal screening according to ethnicity and socio-economic status in the four largest cities of the Netherlands (2011-2013).

OBJECTIVES: In the Netherlands, all women are claimed to have equal access to prenatal screening (PS). Prior research demonstrated substantial inequalities in PS uptake associated with socioeconomic status (SES) and ethnic background. The suggested pathway was a lack of intention to participate in PS among these subgroups. We studied the background of inequalities in PS participation, challenging intention heterogeneity as the single explanation. METHODS: Multivariable logistic regression analyses of the national PS registry, focusing on the four largest cities in the Netherlands (n = 4578, years 2011-2013), stratified by SES. OUTCOME MEASURES: (1) any uptake of PS (yes/no) and (2) uptake (one/two tests) for women who intended to participate in two tests. Determinants included intention, ethnicity, practice, and age. RESULTS: Of non-Western women, 85.7% were screened versus 89.7% of Western women. Intention was an important explanatory factor in all models. However, after correction for intention, ethnicity remained a significant determinant for differences in uptake. Ethnicity and SES also interacted, indicating that non-Western women in low SES areas had the lowest uptake (corrected for intention). CONCLUSIONS FOR PRACTICE: Socioeconomic status and ethnicity related inequalities in PS uptake are only partially explained by intention heterogeneity; other pathways, in particular provider-related determinants, may play a role. © 2017 John Wiley & Sons, Ltd.

An Audit of Second-Trimester Fetal Anomaly Scans Based on a Novel Image-Scoring Method in the Southwest Region of the Netherlands.

OBJECTIVES: Since 2007 the second-trimester fetal anomaly scan is offered to all pregnant women as part of the national prenatal screening program in the Netherlands. Dutch population-based screening programs generally have a well-described system to achieve quality assurance. Because of the absence of a uniform system to monitor the actual performance of the fetal anomaly scan in 2012, we developed a standardized image-scoring method. The aim of this study was to evaluate the scanning performance of all sonographers in the southwestern region of the Netherlands using this image-scoring method. METHODS: Each sonographer was requested to set up a digital portfolio. A portfolio consists of five logbooks from five different pregnant women, each containing 25 fetal anatomical structures and six biometric measures of randomly selected fetal anomaly scans. RESULTS: During the study period, 425 logbooks of 85 sonographers were assessed as part of the audit process. Seventy-three out of 85 sonographers (86%) met the criteria in the primary audit, and 12 sonographers required individual hands-on training. A successful assessment was achieved for 11 sonographers in the re-audit and one sonographer ceased her contract. Moreover, 2.1% of the required images were not digitally stored and therefore could not be reviewed. CONCLUSIONS: Quality assessment using the image-scoring method demonstrated that most of the sonographers met the expectations of the audit process, but those who had subpar performance met the expectations after retraining.

The provision of information and informed decision-making on prenatal screening for Down syndrome: a questionnaire- and register-based survey in a non-selected population.

OBJECTIVE: Evaluating the information provision procedure about prenatal screening for Down syndrome, using informed decision-making as a quality-indicator. METHODS: Questionnaire- and register-based surveys. Midwives associated with 59 midwifery practices completed process data for 6435 pregnancies. Pregnant women (n=510) completed questionnaires on informed decision-making. RESULTS: Midwives offered information to 98.5% of women; 62.6% of them wished to receive information, of these, 81.9% actually received information. Decision-relevant knowledge was adequate in 89.0% of responding women. Knowledge about Down syndrome was less adequate than knowledge about the screening program. Participants in the screening program had higher knowledge scores on Down syndrome and on the screening program than non-participants. Of the women who intended to participate (35.8%), 3.1% had inadequate knowledge. A total of 75.5% of women made an informed decision; 94.3% of women participating in the screening program, and 64.9% of women not participating. CONCLUSION: This quality assurance study showed high levels of informed decision-making and a relatively low participation rate in the national screening program for Down syndrome in the Netherlands. Knowledge of the Down syndrome condition needs to be improved. PRACTICE IMPLICATIONS: This evaluation may serve as a pilot study for quality monitoring studies at a national level.