We drew up a comprehensive list of topics addressed in existing maternal education programs, based on a systematic review of information obtained from the Internet and the experience of the research team. The topics were presented to a multidisciplinary panel whose members were asked to rate them from 1 to 9, and consensus of opinion was reached using a two-round Delphi survey, with consensus defined beforehand as 80% agreement among panelists in awarding a score of 7, 8 or 9. The most highly-rated topics were then discussed and again prioritized by a multidisciplinary team of healthcare and non-healthcare experts, using a nominal group technique.
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In order to identify the topics for special attention during pregnancy, labor, birth, the postpartum period and childrearing, we carried out a mixed methods study in three phases: 1.- a comprehensive description of content related to pregnancy, labor, birth, postpartum, breastfeeding and childrearing addressed in existing maternal education programs and parenting websites; 2- prioritisation of topics using the Delphi method; and 3.- selection of the five highest priority topics, by seeking consensus among experts, using the nominal group technique. The combined use of these two approaches should allow us to reduce any potential bias arising from each independently [28, 29].
This proposal introduces an implementation strategy distinguished by several innovations: (1) a systematic process for clinical guideline translation; (2) a peer-to-peer consulting intervention that integrates relevant theory with empirical research on organizational change [1,14,15]; and (3) an explicit focus on process as a cause of variation in outcomes [29]. The SCS consists of a series of generalizable steps, including setting the larger context (patient safety); teaming clinical guideline writers with implementation specialists and clinical practitioners to distill the essence of the guideline into a succinct, checklist-based implementation guide; providing an outside systems consultant (i.e. a coach) with clinical expertise and experience; actively involving clinical staff (including primary care physicians, nurses, and physician assistants) in the implementation process; giving participants the ability to customize interventions (rather than using a one-size-fits-all approach); and providing tools, such as the walkthrough exercise, Plan-Do-Study-Act change cycles, the nominal group technique, and flowcharting, that promote problem-solving and rapid, incremental improvements.
We will follow NIH guidelines for mixed-methods inquiry [50] to complement quantitative assessments of the feasibility, acceptability, quality, and preliminary effectiveness of the SCS. During the intervention, we will use a variety of qualitative methods, including document review, activity logs, debriefing conversations with the system consultants, and observations of interactions between the systems consultants and the clinic change teams. These methods are designed to help us identify the incentives, scheduling, delivery methods, and other processes and structures that will make the SCS useful for participating clinicians and manageable for the systems consultants. Post-intervention focus groups will be used to compare the experience of clinics that changed substantially versus those that did not. We will explore questions such as (1) What kinds of process changes were associated with improvement? (2) What factors helped providers and clinics make changes? (3) What were the barriers to improvement, and how were they addressed? (4) When the intervention did not work well, what was different?
Techniques for prioritization in community settings range from simple to more complex consensus building techniques, such as straight voting, weighted voting, nominal group technique, consensus panels, focus groups, Delphi technique, and others. The simplest form of community prioritization often occurs in town hall meetings or board meetings using simple voting, which typically implies giving each stakeholder the opportunity to vote on a list of issues. A variation of simple voting is the assignment of a certain number of votes to each stakeholder (e.g., 3 votes) and then sorting ideas or ranking to select the top one. Although democratic, this form of prioritization can only be used when the number of choices is small, and it is sensitive to issues of representativeness and generalizability. However, such a decision-making approach becomes increasingly cumbersome and impractical as the number of priorities increases. Another issue with straight voting is that it takes up only the majority of opinions and may inadvertently alienate a minority group, which can result in detrimental consequences for the community partnership and the engagement process. Some community advocates also use weighted voting, in which stakeholders assign different points (e.g., 1 = low importance, 2 = medium importance, and 3 = high importance) to a list of community issues in order to rank the items posteriorly. Although such a process tends to be more equitable, this method assumes that decision-makers are capable of mentally assigning reliable weights of diverse issues. This assumption is impractical because unguided stakeholders will reflect their personal preference and there is no guarantee that they will use uniform and consistent defensible criteria for prioritization every time they vote.
This study examined the development of a quantifiable indicator for priority setting that we have referred to as the Community Priority Index (CPI). We utilized two criteria (importance and changeability), as well as stratified by subpopulations. We consider that our CPI is a new measure that fosters the accountability of decision making, while flexibly allowing for the application of diverse participatory methodologies. For example, the list of issues that must be prioritized can be generated through nominal groups, focus groups, community surveys, or even expert opinions. However, if the CPI is used in conjunction with democratic participation and adequate community engagement processes, the decision of prioritizing will explicitly incorporate aspects of relevance and changeability. Thus, rather than replacing other methods, we recommend the CPI as an additional tool that can be incorporated to community-based efforts for priority setting, if acceptable and relevant for the community and project context. 2ff7e9595c
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