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Following the conclusion of the ARM@DA realist evidence synthesis in September 2023, we were able to suggest a range of implications to guide implementation of digital consultations (publications coming soon!). However we also found that our ability to make more definitive recommendations was constrained by a limited understanding of current usage patterns of digital consultations in maternity services. Ongoing digital transformation programmes mean that Trusts are undergoing many changes in the way they deliver care.
From ARM@DA it became clear that: (i) there is variability in practice in the use of digital consultations across NHS maternity services, (ii) there is a lack of information about current use of digital consultations in maternity care, and (iii) there is a lack of information on what kinds of guidance is being used to inform good practice. Our evidence review highlighted concerns that remote consultations have the potential to exacerbate health inequalities, but there is a lack of data on how this is being addressed in practice.
To address these information gaps, the ARM@DA team has secured funding to conduct an online survey of senior maternity care professionals in order to map current use of digital consultations in England. Further details on how eligible individuals can take part will be coming soon.
Mapping survey – participant information sheet
The ARM@DA project has been guided throughout by two stakeholder groups. One was made up of women and community organisations, and another of healthcare professionals.
We are very grateful for the support and contributions of these stakeholder groups and their input has really made a difference.
If you were a member of one of these groups, click here to read the ARM@DA Stakeholder Project Summary.
The ARM@DA research team is pleased to invite you to a free webinar in which we will share the findings and recommendations of our realist review into the use of digital (remote) clinical consultations in maternity care.
Join us on 6th September to learn more about the project, our findings and recommendations. The webinar will be held on Microsoft Teams.
Book here.
By Benash Nazmeen Assistant Professor in Midwifery at the University of Bradford and consultant on ARM@DA with a special interest in Health inequalities and Equality, Diversity and Inclusion, and ARM@DA Research Fellow Georgia Clancy.
Research is an essential aspect of healthcare, but it has not always been inclusive of diverse populations. Historically, research has been conducted on specific groups, often excluding individuals from underrepresented communities. As a result, research findings may not accurately reflect the experiences of these groups, and this can lead to disparities in healthcare.
However, there is now a growing recognition that research needs to be more inclusive and that all individuals, regardless of their background, should be actively included and approached to participate in research. When designing the ARM@DA project, we were acutely aware of the current inequalities in UK maternity and the importance of making our work inclusive. In this blog, we’ll be reflecting on some key Equality, Diversity, and Inclusion (EDI) steps that we’ve incorporated into ARM@DA.
Making Research More Inclusive from the start
To make research more inclusive, researchers need to actively seek out and include individuals from diverse backgrounds in their studies. This includes individuals from underrepresented racial and ethnic groups, individuals with disabilities, and individuals from different socioeconomic backgrounds. This should be incorporated within the proposal, aiming towards representation of the national, regional or local demographics.
Since ARM@DA is a realist review we aren’t conducting empirical research. However from the start we established stakeholder groups to shape and refine the project. We’ve partnered with community organisations and advocates such as the Nottingham Maternity Research Network (NMRN), Sister Circle (formerly Women’s Health & Family Services) and the National Autistic Society to help establish these groups. Community engagement can help build trust and facilitate a more meaningful collaboration between researchers and those closest to the topic. We’ve meet with our stakeholder groups periodically to update them on the project, get their feedback on where we’re at and ideas for going forward.
To help overcome barriers to participation, we’ve provided compensation to our stakeholders in appreciation of their time and effort. We’ve also asked them to complete a short, anonymous demographic questionnaire so that we can report on the level of diversity we achieved and consider the impact on the project.
Incorporating EDI into screening, coding and analysis
When screening papers for inclusion in our realist review, we were particularly sensitive to studies reporting on under-presented groups and increasingly became aware of the lack of data currently published on people from diverse backgrounds.
When extracting the study characteristics we paid close attention to the EDI of those studies, taking note of those reporting on participant characteristics such as race, ethnicity, language and socio-economic status to help contextualise their findings. This also helped us understand the extent to which the review would allow us to speak to the experiences of a diverse range of women.
Our sensitivity to EDI continued into the coding and analysis stages, helping us to identify patterns and trends in the data. For example, that individuals from certain racial or ethnic groups could experience a higher burden or specific barrier to accessing digital maternity care. By understanding these patterns, as well as the strength of the data supporting them, we adapted our research strategy to include more consultations with underrepresented groups to strengthen our findings. This will also influence the recommendations we make to help address disparities and promote more equitable (digital) healthcare.
Finally, we try to be reflexive as a team by discussing our own positionalities and privileges that impact our approach to the ARM@DA project, our interpretation of data and presentation of findings.
Benash’s top tips for inclusive healthcare research
- Educate yourself on EDI principles and their importance in research.
- Seek out partnerships with community organisations and advocates to help recruit diverse participants.
- Ensure that informed consent documents are written in plain language and are culturally appropriate.
- Regularly assess the diversity of your research team and actively seek out diverse perspectives and experiences.
- Consider the potential impact of your research on marginalised communities and seek out opportunities to promote equity and social justice in healthcare.
Hello, we are Helen Spiby and Kerry Evans, midwife researchers on the ARM@DA team, contributing an understanding of maternity policy and practice. We are co-investigators on the project and have been involved from the very beginning in identifying the research focus and establishing this as a priority in a maternity context changed by the pandemic.
Remote consultations are not new to the maternity context. It will always be the case that some women live at a distance from some or all their maternity care providers. Previously, remote consultations were only available by telephone in the UK setting. Important decisions take place as a result of telephone conversations – whether it’s to travel to the maternity unit during labour or for support with infant feeding and it’s important for both families and maternity professionals that these go well. The pandemic brought rapid changes to digital maternity consultations, for example video is now used more widely and there is growth in the role of at-home self-monitoring devices. At the centre though are important considerations about which aspects of maternity care can safely be provided digitally.
In Mark’s blog about conducting the literature search for ARM@DA he talked about identifying search terms. These search terms needed to be broad enough that all the relevant data on digital consultation in maternity care would be captured, but also focussed enough that the team wouldn’t be overwhelmed with papers to screen. One of the tricky parts of the screening process was establishing the screening inclusion criteria. Part of our job on the project has involved helping to define which aspects of maternity care should be included in the ARM@DA realist review and which areas fall out of scope.
So, where are the boundaries to maternity care?
Maternity care professionals often work with other professionals to provide care to women in pregnancy and following birth. For example, diabetic teams, specialist mental health services, medicine and physiotherapy services may all contribute to a woman’s care. All these contributions are important but not all these professionals will consider themselves as providers of maternity services. As a general rule, we tried to think about whether a service/intervention was something that a maternity care professional would provide themselves or signpost a woman to. For example women may be signposted to other healthcare professionals or services for support with smoking cessation or specific mental health support; therefore papers about these topics would be excluded.
We considered some of the service provision that we knew had moved online during the pandemic, for example, group antenatal education provision. This enabled us to further define the purpose of the online encounter – whether education or information-oriented, monitoring of specific medical conditions or usual components of maternity care.
To help us define our inclusion criteria further still, we considered it from a commissioning perspective; what would be included in maternity service commissioning and what might be commissioned through other systems? However we recognised that this process was not always clear cut, not least because there was likely to be regional and international variation in the delivery and commissioning of maternity services. For papers that fell into this ‘grey area’, wider discussion in the research team was often necessary.
Fundamental to all of this were the team’s consultations with maternity care professionals, with both clinically-facing and strategic roles, service providers and women and carers about the types of digital care that were introduced before or during the pandemic. From these, we developed a working definition which helped to establish the inclusion criteria for our literature search. This enabled us to utilise only those papers which were most useful to the ARM@DA research questions.
By Georgia Clancy, ARM@DA Research Fellow.
In our previous blog, Mark explained how he conducted the literature search for our realist review. This search produced nearly 6,500 texts! The team needed to sort through these papers so that we would be left with only those highly applicable to ARM@DA. In this month’s blog, we’ll discuss the screening process and share our reference list of included papers to date.
There are a number of different ways that you can carry out the screening process for a review project. You can use Excel or Word, a citation managing software, or a specialist screening and data extraction tool. For the ARM@DA project we chose to use Covidence, a web-based collaboration platform for literature reviews.
We found Covidence to be a useful and efficient tool. It broke down the screening process into different stages, automatically moved papers around depending on if they were voted in or out of the review, and allowed multiple team members to support the screening process. During ‘title and abstract screening’ we voted ‘yes’, ‘no’ or ‘maybe’ to papers. During ‘full text screening’ we set up our exclusion criteria in Covidence so that we could select and record the reason for exclusion. Our screening process was led by Catrin and Georgia, who screened independently to reduce bias. At each stage of the screening process Covidence would keep track of any papers where Catrin or Georgia had made different decisions. These would be placed into the ‘conflict’ section for them to discuss periodically. We also had a third team member on standby to give the casting vote, if necessary.
Once full text screening was complete we were left with a long list of 142 papers (read here: Included studies as of 09-09-22). These will be taken through to a more detailed appraisal process to further identify the most relevant studies for ARM@DA.
Hello, I’m Mark Clowes and I’m the information specialist on the ARM@DA Project team. So what is an information specialist and why does this research project need one? As our previous blog explained, the ARM@DA realist review involves consulting recent research and stakeholders to explore the use of remote/digital maternity care. My job focusses on the first part…
Anyone can find information online using Google; however if this is the only way you search, it’s easy to miss something. So a project like ARM@DA calls on a librarian or information specialist like me to be sure they don’t miss something important. We try to search in a “systematic” way so that those who fund, use and benefit from the research can be confident that the team has found everything that matters. Most research is reported in journal articles – essentially magazines aimed at research and professional audiences – but relevant knowledge is also found on websites; reports from organisations; conference papers; or academic dissertations.
When I start a project such as ARM@DA I follow a few stages:
Conceptualising the question: breaking the topic down into building blocks such as Who? Does What? and What Else Could Be Done? With What Result? In our case, our population (pregnant women) is the Who? and the intervention of interest (digital/remote care) is the What?
Identifying search terms: We can’t count on previous researchers using exactly the same terms as us; a service for pregnant women might mention specific parts of the maternity journey (e.g. antenatal or postnatal) or different clinical specialties (e.g. midwifery; obstetrics). Do authors mention “remote care” or have they used technical words (telecare/telemedicine/online consultation) or the names of apps (Skype or Zoom)? We also rely on our project advisors and stakeholders to tell us about specialist clinical software we may have otherwise missed.
Choosing sources: Where do I look? I use a mixture of search engines like Google Scholar and free specialist databases such as PubMed or The Cochrane Library as well as subscription resources such as CINAHL or EMBASE. Some of these sources add extra descriptive information making it easier to “map” our search words to relevant journal articles.
At this point in a project I am ready to “execute the search”.
Even though I have been doing this a long time I rarely get a new search “right first time” and often have to “fine tune” my first attempt. I need to balance the risk of missing something relevant against drowning the team in thousands of
irrelevant results! For ARM@DA my searches found about 90% of our included papers. For the rest we relied on suggestions from experts, checking reference lists of useful papers and similar “safety net” techniques. Again it’s worth remembering that lots of clinical expertise and good practice doesn’t even get into print – yet another reason why we need women, the public and clinical staff to suggest what we have missed!
ARM@DA, as a “realist review”, differs from other types of review. We search in two phases; first to look for suggestions (“programme theories”) from healthcare workers, women and others to explain why remote care may or may not be a good way of delivering care. Then we look again at the literature to see whether any research backs up (or offers alternative views on) what they have suggested. As the information specialist I aim to identify studies that are rich in detail; highly relevant to the UK, and rigorous (high quality research). The ARM@DA research team then sorts through what I have found to make sure our project covers all the various systems in use. They also want to reflect the fact that pregnant women are not a single group but vary in terms of ethnicity, culture, age and social
background, but not all groups are equally visible in published research.
Reviews are a team effort and my search is only the first stage; but this systematic approach should provide a strong foundation for the rest of the project. My last take before passing on the baton to the reviewers is to keep records of how I have searched so that you, as a future reader of/listener to our research can be sure that we have made strenuous attempts to identify the best available evidence and that our review will help pregnant women to identity the best care for their situation.
By Georgia Clancy, ARM@DA Research Fellow.
Welcome to our first ARM@DA blog! This is the place where we’ll be providing updates, thoughts and reflections as the project goes on.
ARM@DA is a realist inquiry into maternity care at a distance. The aim is to understand when, where and for whom digital (remote) consultations are useful in maternity care services. Our project involves talking to women and healthcare professionals, as well as looking at existing research to get a better picture of how remote consultations should be used in future. We’re currently about half-way through ARM@DA, so we thought we would start our blog with an update on Phase 1.
The aim for Phase 1 was to develop a set of initial programme theories (IPTs) to explain how digital clinical consultations can work best. These IPTs would then guide later phases of the review.
We started by consulting the ARM@DA project advisory group, which consists of clinicians and researchers who can advise, shape and support the project. We also met with our stakeholder groups which are made up of healthcare professionals, services users and community organisations with maternity experience. These discussions helped us to focus and prioritise our work.
Next, we carried out a literature search to identify theory-rich evidence (including empirical papers, reviews, policy documents, guidance and theory). These texts were appraised and the relevant data extracted to generate context-mechanism-outcome (CMO) configurations. CMOs are a key part of realist inquiry, and are used to illustrate the context (the environment in which digital consultations happen), the mechanisms (the resources you need for digital consultations, including how people respond) and the outcomes (the potential effects of digital consultations). After we developed the IPTs we presented them to the stakeholders for feedback and refinement. For now, we’ve split our IPTs into those which relate to women (as service users) and those which relate to healthcare professionals and the organisations in which they work.
For women, our work so far suggests two main points. First, that women’s preferences for telephone or video consultations can vary a lot depending on their personal situation. So, it is important to take an individualised approach. Second, remote consultations may be difficult for some groups of women (e.g. women who don’t speak English well or who don’t have good internet access). So, it will be important for maternity services to think about how to make remote care accessible (to those who want it).
For staff, our work so far also suggests two main points. First, that it is important to have good systems, training and support at work so that remote consultations can be easily adopted. Second, staff feel it is important that they can make decisions about when to use remote consultations, so that they can be flexible and adapt care to meet women’s needs.
Our next step is to test and explore our IPTs in Phase 2. We’ll be sure to let you know how it goes!