We first present the findings from the in-depth interviews with pregnant women and healthcare providers and second, how we utilized these findings in iterative rounds of development and evaluation of the TCC intervention with users.
Part I: Findings from in-depth interviews
Among 18 interviewed pregnant women, seven had a high-risk condition in the current pregnancy, and seven were primigravida. The participants mean age was 26 years, ranging from 20 to 33 years. All interviewed women had formal education and seven of them held a college degree or above.
We present pregnant women’s perceptions of the prioritized high-risk conditions (anemia, HDP, GDM, and FGR) and untimely ANC attendance using the HBM (Table 1). We also present results from healthcare providers’ perspectives and experiences, where relevant.
Table 1: Health Belief Model constructs including the main themes with quotes from the participants, Palestine.
Model constructs
|
Description of the themes
|
Example excerpts
|
Perceived susceptibility
|
Knowledge: Susceptibility is perceived as higher among women who know the complications that can develop in pregnancy
|
“I don’t know about the disease, so how can I know if I am susceptible to it or not.”
- a primigravida
|
Self-care: Women perceive lower susceptibility as they engage in preventive self-care (e.g. healthy diets) and follow recommendations of care providers (e.g. ANC and screening)
|
“No, because I came to the clinic every time, and they [healthcare providers] reassured me that I didn’t have anything worrying. Also, in fact, I do not like sweets and sugar.”
- a primigravida
“I do not think so, because I am eating a good diet. As long as you have a good diet and milk and your hemoglobin is 12 and you are at the end of your pregnancy…”
- a low risk woman
|
Pregnancy history: Women with complications in previous pregnancies perceive themselves as more susceptible
|
“Yes, I had it [hypertension] in my first pregnancy and I recovered after delivery. Yes, I am susceptible because…”
- an 8 months pregnant woman
|
Family history: Women with a family history of pregnancy complications or chronic conditions perceive themselves as more susceptible
|
“No I don’t worry, and there is nobody in my family who has diabetes”
- a 29 year old hypertensive woman
“I don’t know exactly, my parents don’t have hypertension and my husband’s parents have hypertension, so may be my children will have hypertension in the future.”
- a pregnant woman who had miscarried five times
|
Perceived severity
|
Chronic conditions, not pregnancy complications. Women relate their perception of severity to the conditions as chronic conditions, but not their potential for complicating pregnancy
|
“I know that diabetes delays healing of the wound and this may cause amputation of limbs…”
- a woman attending a high-risk clinic
“Heart problems and increase heart rate, dizziness and loss of consciousness”
- a low-risk woman
“I do not know if it affects [the baby]”
- a 20 year old primigravida with moderate anemia
|
History of friends/relatives: Women who know friends/family with a history of pregnancy complications perceive complications as more severe
|
“…hypertension is dangerous for pregnant women and leads to preeclampsia, I know a friend who had eclampsia at the end of the eighth month”
- a multigravida
“My sister had anemia and her hemoglobin became 5, and she needed two units of blood…”
- a grand multipara
|
Being affected by a complication: Women diagnosed with a high risk condition, often articulate clearly the potentially severe consequences of the condition
|
“Premature baby, low birth weight or IUGR”
- a pregnant woman in a high-risk clinic
“It can cause early labor, bleeding and thrombosis”
- a woman with coagulation disorder
|
Perceived benefit
|
Expectations to care content: Advance knowledge of purpose and what tests each scheduled visit would include, affects the women’s perception of benefit
|
“I found that [private] doctor and [public] clinic providing the same services, such as weight, height, blood pressure measurements, so I decided to follow up in the [public] clinic”
- a pregnant woman at low-risk clinic trying out services in Gaza
“I have to come. It is my duty to come for ANC visit”
- a primigravida
|
Being affected by a complication: Women diagnosed with a high risk condition perceive the importance of visiting the clinics according to the schedule, but only for the specific condition they are diagnosed with
|
“…examine the level of sugar and control…”
- a woman attending a high-risk clinic
“I follow my periodic check-ups every month …I receive the anticoagulant injections…”
- a woman with coagulation disorder
“Of course it is beneficial, since I get the anti-hypertensive drugs, iron and vitamins”
- a woman diagnosed with HDP
|
Perceived barrier
|
Perception of benefits: The better the perceived benefit the woman have, the less perceived barrier to attend the scheduled visits
|
“I think that there are no obstacles, and I should follow the right things for my benefit.”
- a primigravida
“I think, there are no difficulties, and the most important thing is having personal will”
- a grand multipara
|
Family logistics: Women with small children and little family support, report this as a barrier to attend ANC
|
“In the first and second pregnancies, I attended regularly, but when the number of my children increased, it became less often than before.”
- a mother of three
“…my children are small and my husband works in military and he comes back at night…”
- a multipara
|
Perceptions of high-risk conditions and timely attendance
Perception of susceptibility and severity: Pregnant women, in general, perceived that they had low susceptibility to the high-risk conditions, and that these had low severity. Women with knowledge of the high risk conditions, a history of pregnancy complications, or knew someone with a history of pregnancy complications, perceived greater susceptibility to the high-risk conditions compared with their peers. Women engaged in self-care activities, such as healthy diet, exercise, and regular checkups, perceived themselves as less susceptible to pregnancy complications compared with women not engaged in self-care activities. Most pregnant women knew the general consequences and complications of anemia, diabetes, and hypertension as chronic diseases for the general population, but not their effects in pregnancy on maternal and fetal outcomes (Table 1).
Perceived benefits of timely ANC attendance: Pregnant women recognized the benefits of attending ANC on wellbeing, both for their baby and themselves. However, they had little awareness of the importance of timely ANC attendance for appropriate screening and management. The pregnant women’s perceived benefits of attending ANC for screening and management of high-risk conditions were affected by individual background characteristics. Women identified with a high-risk condition or with a history of a pregnancy complication, attended ANC more often than women without any current or previous complications. These women were also more aware of what to expect during ANC visits and the importance of timely attendance. Primigravida women were eager to attend ANC, but had low awareness of what to expect regarding screening and management activities, and the importance of timely attendance. Healthcare providers reported that they provided attractive ANC services to women that contributed positively to women’s ANC attendance (Table 1).
Perceptions about barriers, cues-to-action, and self-efficacy: In general, women’s perceptions of barriers, lack of cues-to-action, or lack of self-efficacy were not main factors preventing women from attending ANC services. Among women interviewed, the majority reported that accessibility and lack of support from the husband and/or other family members were not a problem. However, a few women with young children stated that lack of support in childcare was a barrier for them to attend ANC. Low perceived benefits from ANC attendance, along with low perceptions of susceptibility to, and severity of, the high-risk conditions, were the main barriers to timely ANC attendance.
Most women attended ANC despite the lack of cues-to-action, such as a formal appointment reminder system. However, both healthcare providers and women indicated that healthcare providers sometime contact women with a missed appointment via phone or through social networks including family members. Healthcare providers pointed out that these approaches are time consuming and done irregularly. Women diagnosed with a high-risk condition and perceived this as severe, attended ANC due to their concerns. As one midwife pointed out, “…they feel it is important for them, they write the date on their mobile so that they don’t forget it”
Regarding self-efficacy, almost all women said that they independently decided to attend ANC, and that they were confident about their choice. They also reported that they have adequate social capital to do so. One interviewee said, “Inshalah, since I am educated, I can do the right thing.”
Pregnant women’s awareness, health information sources, and counseling
All pregnant women had heard of anemia, HDP, GDM and FGR. However, their awareness and descriptions of causes and consequences, varied based on the level of education, parity, personal history and knowing someone with at least one of the conditions. Women diagnosed with a condition were more aware of that condition and followed its progress more closely, compared to women not diagnosed with any of the high-risk conditions. Most of the diagnosed women remembered lab results, such as hemoglobin levels over time (Additional file 3 a).
Healthcare providers, especially MCH doctors, were the main trusted sources of pregnancy related information. Several women also use the internet or ask their mothers if they need the information immediately. If they do not understand or find contradictory information, they prefer to confirm it with a doctor (Additional file 3 b).
Most women felt that they received adequate health information during ANC visits (Additional file 3 c). Women diagnosed with one of the high-risk conditions received information regarding that specific condition. Healthcare providers stated that they spent less time on counseling and health education than desired, due to the high patient load (Additional file 3 d). Some pregnant women who were diagnosed with a high-risk condition (Additional file 3 e) confirmed this.
Attendance at ANC
Almost all women stated that they visited the health facility when they missed a period, and most healthcare providers had observed an increasing trend in early initiation of ANC. Most women were committed to scheduled ANC visits, but the degree of adherence differed based on their background characteristics, such as education, parity, and previous adverse pregnancy outcomes (Additional file 3 f). Healthcare providers also said that most women are committed to scheduled ANC visits, including those with low-risk pregnancies. Women showed an interest in more frequent visits than currently recommended (Additional file 3 g,h).
In sum, the in-depth interviews indicated that many women had limited knowledge about pregnancy related anemia, HDP, GDM, and FGR, and perceived the susceptibility to, and severity of, such conditions as low. While the general motivation to attend ANC was high, awareness of the importance of timely attendance to be appropriately screened and managed for such conditions was low. Women with high exposure to information about such pregnancy-related complications and the role of ANC (i.e. complications in current or prior pregnancy, knowing someone who experienced it, etc.) had high awareness of both the susceptibility to and severity of the conditions, as well as the benefits of timely ANC.
Part II: Composing the text messages
We used the findings from the in-depth interviews above to identify gaps in information and awareness, across the HBM constructs, to be addressed in the TCC intervention. The national ANC guidelines recommend specific interventions towards the prioritized pregnancy related conditions in ANC visits at specific gestational ages (Additional file 1). We identified the five sentinel visits, corresponding to the specific time windows, as an opportunity to provide timely and actionable text messages based on the Model of Actionable Feedback. Actionable reminders of scheduled sentinel visits were combined with information about the susceptibility to and severity of the prioritized pregnancy related condition to be addressed, and the benefits of attending this sentinel visit. The text messages were co-designed iteratively with users. The Enhanced Active Choice, nudging theories and the Model of Actionable Feedback guided the framing, composition and timing of each text message.
Intervention structure: target condition, frequency, timing and intensity
We developed text messages to be delivered in concert with the five sentinel recommended visits (gestational week <16, 18-22, 24-28, 32 and 36) [34] in addition to a welcome message sent at the time of enrollment. The content of the text message corresponding to each sentinel visit was, among other factors, determined by the prioritized pregnancy related condition to be addressed through a screening test at that visit (Additional file 1). We applied the following message types and frequencies per visit:
- One week before a scheduled sentinel visit: Women with a scheduled sentinel visit within an appropriate gestational age window, described above, receive this message. The message content addresses the benefit of attending ANC and the susceptibility to and, severity of the specific high-risk condition to be screened for, at that visit, according to national guidelines.
- Three days before scheduled sentinel visit: Women with a scheduled sentinel visit and only with risk factors for the high-risk condition receives this message. The content addresses the increased susceptibility to, and the benefit of ANC attendance to be screened for timely. We use “scaled intensity” to intensify the intervention for those with the highest needs.
- 24-hours before any scheduled visit: All women with a scheduled visit irrespective of the gestational age receive this simple reminder.
- 24-hours after missed appointments for a sentinel visit: Only women with a missed appointment for a sentinel visit receive this reminder to re-schedule the appointment.
The package of text messages included continuity of care and postpartum care messages (Figure 1). To illustrate, a woman above 34 years of age without a diagnosed high-risk condition, will receive 19 text messages if she starts ANC before gestational week 15, and is scheduled for and attends all five sentinel visits (Figure 1). Missed appointment reminders would be additional.
Content and framing of the text messages
The content in the text messages addressed key themes within the HBM constructs identified in Part I (Table 2). To address gaps in perceived susceptibility, the text messages included information about a woman’s relative chance of getting each high-risk condition (Table 2). We followed message-framing concepts and expressed proportions in an “x in y” format. For women with risk factors, we stated the risk factor and the increased susceptibility to the corresponding high-risk condition.
We stated the consequences of each high-risk condition to both the woman and her baby to address the perceived severity, given that most women knew the general population consequences of the chronic disease, but not the specific adverse effects during gestation. We avoided serious and grave consequences, such as death or malformation, to prevent unwarranted worries in pregnancy. We presented the potential screening tests that could detect each high-risk condition to address the perceived benefits (Additional file 1).
Table 2: Content creation for the identified constructs of the Health Belief Model and the application of selected concepts to structure and frame messages, an example
Targeted HBM constructs
|
Gaps and considerations
|
Source of information
|
Example phrases
|
Perceived Susceptibility
|
· Specifying risks to pregnancy
|
· Finding from part I
|
1 in 20 develop high blood pressure in pregnancy.
|
· Statistics
|
· Nudging concept
|
· Scaled intensity: more messages to those with risk-factors
|
· MAF
· Nudging concept
|
Perceived Severity
|
· Consequences to the baby and the women herself
|
· Findings from part I
|
This can affect the baby's nutrition and growth. If not measured and managed, it can affect your health too.
|
· No mentioning of severe/grave consequences
|
· EAC and MAF
|
Perceived Benefits
|
· Guideline based available screening services at the PHCs
|
· Mapping: ANC guideline
|
We will measure your blood pressure and proteins in your urine that can be a sign of high blood pressure.
|
· Specifying beneficial test beforehand
Personalization
|
· Findings from part I
· EAC
|
· Timed to the benefit
|
· MAF and EAC
|
HBM = Health Belief Model, MAF = Model of Actionable Feedback, EAC = Enhanced Active Choice
The Model of Actionable Feedback [36] and concepts of social nudging and Enhanced Active Choice [11] were used to structure the text messages, and make them action oriented while addressing knowledge gaps, beliefs and perceptions (Figure 2, Additional file 2). Concepts from the Model of Actionable Feedback, including timeliness, non-punitiveness, customizability, and individualization, were among the guiding principles at each stage of the TCC content development, evaluation, and implementation. See Additional file 2 for details on the application of the Model of Actionable Feedback and Enhanced Active Choice in composing the text messages.
Evaluation of the draft text messages
Generally, the content of the text messages was understandable and acceptable after evaluation by health educators, healthcare providers, and pregnant women. Minor changes to a few messages were made based on comments from stakeholders. Contextualized translation into Arabic was preferred over literal translation. Regarding the timing, women preferred to receive the text messages after working hours when they are free to read the text messages.