Contribution to the literature
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Digital tools and resources have the potential to transform antenatal education but only if adopted by healthcare providers as part of everyday clinical practice.
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Several barriers to being an effective educator have been described; yet, previous studies do not always incorporate an explicit process of translating the findings into designing an intervention to affect change.
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This study describes all the stages of the Behaviour Change Wheel process from using mixed-methods to diagnose the issue among midwives in Cyprus to intervention mapping.
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Guided by Participatory Action Research, the process was also instrumental in cultivating a new shared awareness of the issue.
Background
Aim
Methods
Study design
COM-B, TDF and Behaviour Change Wheel
Implementation process
Preparatory phase: rapid literature review
Study A: focus groups and written response to open-ended question
Study B: questionnaire survey
Study C: participatory learning workshop
Ethical considerations
Results
Theoretical Domain Framework | COM-B | Participants | Count | Intensity | Characteristic quote | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | |||||
(1) Skills (physical) | Physical Capability | 0 | 0 | ||||||||||||
Skills (cognitive & interpersonal) | Psychological Capability | √ | √ | √ | √ | √ | √ | √ | 7 | 9 | “The skills needed by a midwife who works in the maternity ward, and operates within routine practice, are different from the ones needed by a midwife working with pregnant women [re: antenatal clinic]” | ||||
(2) Knowledge | √ | √ | √ | √ | √ | √ | √ | "I noticed that each midwife offers different ‘knowledge' [re: information], resulting in confusion and misinformation. This is done either….or … or due to actual lack of knowledge” | |||||||
(3) Memory, attention & decision process | √ | √ | √ | 3 | 3 | "…small number of midwives … As a result, a midwife is often unable to devote as much time as needed to a pregnant woman” | |||||||||
(4) Behavioural regulation | √ | √ | 2 | 2 | "Factors which can facilitate the educational role of the midwife are…., (2) planning of midwifery care, (3) cooperation with other health professionals, (4)…." | ||||||||||
(5) Environmental context & Resources | Physical Opportunity | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | 10 | 18 | “Personal contact presupposes … a suitable space with a desk and a computer, comfortable chairs, beautiful, friendly environment…”, “…available, accessible and good-quality educational material and services… there is insufficient resources…" | |
(6) Social influences | Social Opportunity | √ | √ | √ | √ | √ | √ | 6 | 9 | "…the medicalization of the birth but also the mentality of many Cypriots who always seek the opinion of the doctor" | |||||
(7) Social or Professional Role & Identity | Reflective Motivation | √ | √ | √ | √ | 4 | 8 | “A midwife has a duty to provide equal care to all without discrimination…” “…midwives work with significant limitations in terms of their autonomy” | |||||||
(8) Beliefs about Capabilities | √ | √ | 2 | 3 | “The midwife has accepted this way of working, to monitor the pregnant women only at the time of childbirth… as a result she does not train more, does not specialize, does not take initiative and does not assume her educational role beyond the moment of childbirth and for breastfeeding support” | ||||||||||
(9) Beliefs about Consequences | √ | √ | √ | √ | √ | 5 | 6 | "[A midwife] has an important role to play with regard to counselling and education, not only for the women but also for the whole family, as well as for the community. Her work includes prenatal education and preparation for parenting but can be extended to women's health, sexual and reproductive health, and pediatric care” | |||||||
(10) Optimism | √ | √ | √ | 3 | 3 | “Today's midwives must have the courage [to dare] to showcase their abilities in order to promote their autonomy as midwives.” | |||||||||
(11) Intentions | √ | √ | 2 | 2 | “…indifference on the part of midwives” “…it depends on the personal will, desire and time each midwife has” | ||||||||||
(12) Goals | √ | √ | √ | 3 | 3 | "… the most important [facilitating] factor is to have or be able to build a relationship based on trust between the pregnant woman and the midwife" | |||||||||
(13) Reinforcement | Automatic Motivation | √ | √ | √ | √ | √ | √ | 6 | 7 | “…there isn’t any common code of practice or guidelines, which if existed the problem would be resolved.” | |||||
(14) Emotion | √ | √ | √ | 3 | 5 | “…increases the job satisfaction and enhances professional autonomy and responsibility in the workplace” |
Domains (N = 14) | Items (N = 83) | Sub-domains (N = 24) | 6-point Likert disagreement agreement scale | Sub-domain score (theor. range 1–6) | Rank (reverse) | ||
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Mean | SD | Mean | SD | ||||
Knowledge | Aware | Procedural knowledge & Role clarity (4 items) | 5.46 | 0.78 | 5.43 | 0.60 | 20 |
Know | 5.54 | 0.66 | |||||
Familiar | 5.25 | 0.94 | |||||
Expected (role clarity) | 5.46 | 0.78 | |||||
Skills | Trained | Skills (4 items) | 5.50 | 0.59 | 5.34 | 0.56 | 19 |
Skills | 5.38 | 0.71 | |||||
Practiced | 5.25 | 0.85 | |||||
Proficiency | 5.25 | 0.74 | |||||
Social/professional role and identity | Part of work | Professional role (4 items) | 5.71 | 0.55 | 5.73 | 0.43 | 24 |
Job as midwife | 5.71 | 0.55 | |||||
Professional Responsibility | 5.75 | 0.44 | |||||
Consistent with profession | 5.75 | 0.53 | |||||
Beliefs about capabilities | Confident – even if participants not motivated | Self-efficacy (3 items) | 5.04 | 0.81 | 5.28 | 0.63 | 17 |
Confident – when little time | 5.25 | 0.85 | |||||
Self-confident | 5.54 | 0.66 | |||||
Control | Perceived behavioural control (3 items) | 4.38 | 1.41 | 4.81 | 0.83 | 10 | |
Difficult-Easy | 4.92 | 0.88 | |||||
Impossible-Possible | 5.13 | 0.95 | |||||
Optimism | Expect best in uncertain times | Optimism (3 items) | 5.13 | 0.99 | 5.32 | 0.66 | 18 |
Optimistic about the future | 5.46 | 0.66 | |||||
Expect more good than bad | 5.38 | 0.71 | |||||
Beliefs about consequences | Benefit mother–child health | Outcome expectancies (5 items) | 5.79 | 0.41 | 5.43 | 0.48 | 21 |
Benefit public health | 5.67 | 0.56 | |||||
Disadvantages for relationship (reverse) | 4.54 | 1.38 | |||||
Satisfaction | 5.63 | 0.58 | |||||
Collaboration with professionals | 5.54 | 0.72 | |||||
Useless – useful | Attitudes (3 items) | 5.58 | 1.10 | 5.72 | 0.57 | 23 | |
Bad – Good | 5.79 | 0.51 | |||||
Not worthwhile—Worthwhile | 5.79 | 0.51 | |||||
Reinforcement | Financial reimbursement | Reinforcement (4 items) | 2.38 | 1.58 | 4.49 | 0.65 | 5 |
Recognition from peers | 4.71 | 1.12 | |||||
Make a difference | 5.21 | 0.88 | |||||
Recognition from participants | 5.67 | 0.48 | |||||
Intentions | Next 10 appointments | Intention (4 items) | 5.42 | 0.95 | 5.63 | 0.52 | 22 |
Determination | 5.54 | 0.72 | |||||
Intention | 5.75 | 0.53 | |||||
Strength of intention | 5.79 | 0.51 | |||||
Goals | Clear plan—Process | Priority (4 items) | 5.17 | 0.76 | 3.98 | 0.67 | 4 |
Clear plan—Frequency | 4.88 | 0.80 | |||||
Higher priority (reverse) | 2.79 | 1.25 | |||||
More urgent (reverse) | 3.08 | 1.02 | |||||
Memory, attention and decision processes | Easy to remember | Memory and Attention (5 items) | 4.92 | 0.93 | 4.76 | 0.70 | 9 |
Forget | 4.96 | 1.23 | |||||
Concentration | 5.00 | 1.14 | |||||
Distracting thoughts (reverse) | 4.21 | 1.44 | |||||
Attention focus | 4.71 | 1.04 | |||||
Environmental context and resources | Institutional financial support | Characteristic of socio-political context (4 items) | 2.79 | 1.32 | 3.65 | 1.14 | 3 |
Good networks between parties | 3.79 | 1.28 | |||||
Fit with routine practice | 4.13 | 1.45 | |||||
Routine in organization | 3.88 | 1.54 | |||||
Enough time | Organizational resources (6 items) | 3.50 | 1.32 | 3.31 | 0.99 | 1 | |
Professional training | 3.96 | 1.37 | |||||
Necessary resources | 3.04 | 1.37 | |||||
Financial reimbursement | 2.33 | 1.20 | |||||
Sufficient material | 3.75 | 1.39 | |||||
Assistance | 3.25 | 1.39 | |||||
Motivation of participants | Characteristics of participants (2 items) | 4.83 | 1.13 | 4.90 | 1.12 | 12 | |
Positive response from participants | 4.96 | 1.16 | |||||
Social influences | Peer acceptance | Subjective norm (2 items) | 5.17 | 0.87 | 5.17 | 0.86 | 14 |
Peer approval | 5.17 | 0.87 | |||||
Rely on team of professionals | Social support (4 items) | 4.42 | 1.28 | 4.57 | 0.99 | 7 | |
Colleagues are willing to listen | 4.63 | 1.17 | |||||
Helpful team of professionals | 4.50 | 1.18 | |||||
Rely on colleagues | 4.75 | 1.03 | |||||
Team of professionals do it | Descriptive norm (2 items) | 4.46 | 1.22 | 4.56 | 1.07 | 6 | |
Respected colleagues do it | 4.67 | 1.17 | |||||
Management support | Organizational support (3 items) | 3.46 | 1.41 | 3.53 | 1.39 | 2 | |
Management willing to listen | 3.46 | 1.44 | |||||
Helpful management | 3.67 | 1.40 | |||||
Emotion | Enjoy normal day-to-day activities | Stress (2 items) | 4.83 | 1.05 | 4.63 | 0.85 | 8 |
Unhappy and depressed (reverse) | 4.42 | 1.21 | |||||
Inspired | Affect: Positive and negative emotions (2 items) | 5.42 | 0.65 | 5.04 | 0.79 | 13 | |
Nervous (reverse) | 4.67 | 1.27 | |||||
Behavioural regulation | Automatically | Automaticity (4 items) | 5.29 | 1.04 | 5.21 | 0.81 | 16 |
Without thinking | 5.13 | 0.99 | |||||
Without having to consciously remember | 5.29 | 1.00 | |||||
Start before realize doing it | 5.13 | 1.36 | |||||
Track of overall progress | Self-monitoring (3 items) | 5.21 | 0.88 | 5.18 | 0.77 | 15 | |
Aware of day-to-day behaviour | 5.00 | 0.78 | |||||
Notice successes | 5.33 | 0.87 | |||||
Planning—when participants not motivated | Coping planning (3 items) | 4.71 | 1.27 | 4.88 | 0.82 | 11 | |
Planning -when little time | 4.67 | 1.09 | |||||
Planning – even if others do not do this | 5.25 | 0.61 |
Capability | Opportunity | Motivation |
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• Continuous education and professional development: seminars, workshops, conferences, specialised training programmes • In-hospital training: absence of formal mechanism for transmission of new knowledge and integration of professional development activities in clinical practice • Lack of targeted training in the educational role for the development of practical skills • Lack of specialist role with training in antenatal education and counselling • Digital skills: using online and other digital resources or new technologies • Strengthening communication skills • Cultural competence skills needed in changing multicultural environment • Critical appraisal skills to keep up-to-date with evidence-based practice • Evidence-based practice skills: Ability to refer to and use evidence in the context of educational capacity | • Inappropriate infrastructure / unfriendly spaces, not offering comfort and privacy • Lack of resources: • Lack of educational and informational material and other resources • Insufficient or non-existent financial resources for the creation of material, even if intention exists • Lack of equipment (e.g. computers) or old-age with no regular maintenance • No access to internet and online sources of information in clinical settings • Barriers to access: • Minimal contact with midwives before childbirth (especially in private sector) • Not institutionalization of educational role of midwives by organizations / healthcare system • Need for establishment of autonomous and complementary role • Direct access to midwives without referral from an Obstetrician -Gynecologist within new National Healthcre system, even if limited • Medicalization: • Understaffing and lack of time • Undervalued: non-recognition of the importance of antenatal education by administration / healthcare system vs midwifery-led care) • Professional role boundaries and inter-professional conflict • Lack of common policy and protocols (roles, actions, referrals, etc.) • Interdisciplinarty/ interprofessional activities: • Weak interdisciplinary collaboration in clinical practice • Incompatible interprofessional activities, values and skills • Need for tighter collaboration and partnerships between professional associations and scientific bodies • Limited availability of joint training programs with other healthcare professionals • Linguistic barriers: Inability to communicate with non-Greek healthcare users/ no translators / little to no material in other languages | • Competing priorities due to work overload / reduced control over decision making • Inefficient human resources utilization • Professional status and identity: Unfamiliarity and lack of trust in midwives due to medicalization of birth • No continuity of care: Fragmented contact with midwife reduces motivation • Decentralization: different roles and responsibilities between state and private maternity hospitals • Educational role as a means for • promoting and showcasing autonomous role of midwives • improving job satisfaction - • Strengthening inter-professional cooperation in the context of developing guidelines, protocols and material • Avoidance of educational role • conflicting views with prevailing medicalised care • incompatible policies and contradictory messages e.g. maternity leave less than 6 months vs recommendations for exclusive breastfeeding up to 6 months • Resistance to change/ complacency due to civil servant status in public sector • No continuity of care –No community midwifery • Lack of incentives, recognition or rewards for professional development • Unequal opportunities for professional development • No formal evaluation system for career progression • No wider culture of continuing education and professional development • Establishment of first midwifery-led natural birth centre reason for optimism |
Phase 1: behaviour diagnosis
Physical Opportunity
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Participant 2: “…small number of midwives … As a result, a midwife is often unable to devote as much time as needed to a pregnant woman”.
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Participant 9: “…midwives meet 2 or even 3 women in the same room at the same time without any privacy…”.
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Participant 1: “Personal contact presupposes the availability of time for discussion and questions, but also a suitable space with a desk and a computer, comfortable chairs, a beautiful, friendly environment…”.
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Participant 1: “…available, accessible and good quality educational material and services …there isn’t sufficient material and resources, …".
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Participant 6: “…the issue of language and communication is an obstacle … a large proportion of women are from abroad … material should be translated and antenatal classes should be provided in other languages or there should be a translator available”
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Participant 7: “…all pregnant women are monitored by the doctor, midwives in hospitals see them for a minute or two for vital signs and in private clinics women do not even come in contact with the midwife, only the doctor”.
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Participant 9: “…there is no contact with the same midwife on every prenatal visit [re: continuity of care], so there is no trusting relationship between midwives and women… this whole thing makes any implementation of the educational role really difficult”.
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Participant 7: "…the time [a midwife] has with the woman is only 3–4 days until discharge, there is no community midwifery. This is a deterrent to assuming an educational role in the first place…”.
Social Opportunity
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Participant 5: “…the presentation of the gynecologist as an authority”.
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Participant 7: “[Re: relationship with doctor]…this is what the system cultivates”.
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Participant 8: “…unsatisfactory communication between midwives and women resulting in lack of trust and unwillingness to collaborate [with the midwife]”.
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Participant 2: “[re: lack of referral system] A midwife should be able to monitor a normal pregnancy, provide advice and refer where needed to the appropriate health professional”.
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Participant 8: "… lack of collaboration with other health professionals and links with provided services, …”
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Participant 9 – “No common code of practice or guidelines, which if existed the problem would be resolved”
Physical Capability
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Participant 5: "… staff shortages is already a problem,…, if an individualized care approach is to be adopted an even larger number of midwives will be required".
Psychological Capability
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Participant 9: "I noticed that each midwife offers different ‘knowledge' [re: information] to new mums, resulting in confusion and misinformation. This is done either…or … or due to actual lack of knowledge by the midwife”.
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Participant 4: "Better training. The training [re: continuous education] is inadequate"
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Participant 1: “The skills necessary for a midwife who works in the ward and operates within routine practice are different to those of the midwife who works with pregnant women [Re: antenatal clinic]”.
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Participant 7: “There is no form of skill assessment”
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Participant 11: "Today's midwives must be well-trained, equipped with best knowledge, experience and skills. A midwife must be in a position to understand, cooperate and communicate, being able to justify every procedure and intervention based on available evidence”.
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Participant 8: “…adequate continuous education …the ability of midwives to combine their clinical knowledge and skills with interpersonal and transcultural skills".
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Participant 1: "There [re: Antenatal Care Clinic], it is much more likely for a midwife to be called upon to answer questions and thus in this way get the chance to develop into the educational role every day…".
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Participant 10: “Midwives involved in antenatal education should follow a specialization programme to become expert educators”
Reflective Motivation
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Participant 8: "[A midwife] has an important role, not only for the women but also for the whole family, and the community. Her work includes antenatal education and preparation for parenting but can be extended to women's health, sexual and reproductive health, and pediatric care".
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Participant 11: "A midwife has a duty to provide equal care to all … we need to appreciate the seriousness of the profession we have chosen”
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Participant 11: “…midwives work with significant limitations in terms of their autonomy.”
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Participant 2: “…no emphasis on antenatal education and care”.
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Participant 4: "One factor that would facilitate the role of the midwife in the future is the implementation of personalized midwifery care. That is, to have a midwife for every four women, for example, so that there is time to dedicate to each woman individually"
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Participant 5: "… through in-hospital mentoring, midwives [re: experienced midwives] can contribute by providing an example to follow".
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Participant 7: "… the informal process by which a midwife acquires the common culture of midwifery, the values, beliefs, attitudes, patterns of behavior and social identity of midwifery"
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Participant 9: “…there is no contact with the same midwife between successive appointments [re: continuation of care]”
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Participant 4: "… after women leave the maternity clinic, there is no contact with the midwives… this is a problem”.
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Participant 7: "A pregnant woman develops a relationship only with her doctor, she only sees the doctor, and has confidence in what he/she tells her, the doctor is the person to refer to for questions”.
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Participant 2: "…the medicalization of the profession but also the mentality of many Cypriots who always seek the opinion of the doctor".
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Participant 7: "The midwife has accepted this way of working …as a result she does not train more, does not specialize, does not take initiative and does not assume an educational role beyond the moment of childbirth and for breastfeeding support”
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Participant 1: “Today's midwives must have the courage to dare to showcase their abilities in order to promote their autonomy as midwives”
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Participant 11: "… expanding the role of the midwife has the potential to provide high quality continuous maternity care to women, which increases the job satisfaction of midwives, promotes and enhances professional autonomy and responsibility in the workplace”
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Participant 4: “… and that’s why there should be Community Midwifery, giving the midwives the opportunity to promote their educational role"
Automatic Motivation
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Participant 10: “…this is without intention, this problem of unequal provision of care, is without intention, but due to the barriers that exist ".
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Participant 11: "… care should not be impersonal and each woman should feel safe and that she can trust what the midwife tells her…”
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Participant 8: “…better distribution of roles and responsibilities based on needs, abilities and resources"
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Participant 3: "Better evaluation system…. more opportunities to gain experience".