Partnering with consumers and practising clinicians to establish research priorities for public hospital maternity services

Introduction

Embedding meaningful end-user involvement in clinical research is critical to establish good research practice, optimise outcomes and maintain a responsive healthcare system. Historically, research programs and research agendas have been at risk of being distorted by commercial and academic priorities that may be misaligned with real-world clinical concerns and the needs of end-users, such as healthcare consumers and practising clinicians.^1,2 The evidence–practice gap arguably exists due to barriers such as these.

Despite burgeoning literature comprising millions of clinical research studies, the usefulness and translational benefit is often limited.³ Editors of high-impact medical journals have voiced concern for the growing number of publications that provide marginal clinical value.^1,4 Less than 7% of all clinical trials are highly relevant to clinical practice.¹ Consequently, there is an international drive to ensure that clinical medicine is more effective, evidence-based, cost-efficient and accountable, with consumer involvement and engagement in clinical research becoming an important global movement.^1,5,6

In 2022 the Australian Government Department of Health implemented the National Clinical Trials Governance Framework outlining that healthcare organisations are to develop, implement and maintain systems to ensure that healthcare consumers are partners in all aspects of clinical research, including the formulation of research agendas.^7,8 Efforts must be made across health care to increase the involvement of consumers and clinicians when identifying research priorities, and ensuring that finite research resources are allocated to guarantee maximal impact for investment.⁹

Research mismatch has been evident in maternity care. Historically, it has consisted of disease-focused or morbidity-driven research programs led by academics, which may not address the needs or aspects of care most important to the majority of pregnant, birthing and postnatal women and their families.¹⁰ By partnering with research end-users during the development and implementation of research agendas, the relevance of the research that health services engage with will be strengthened. Studies demonstrate that healthcare consumers, specifically maternity consumers, are well able to articulate researchable questions when provided with an opportunity and supported to do so.^2,10

Therefore, in response to growing demand for high-quality maternity services and competitive research resources in south-east Queensland, Australia, we undertook a collaborative research priority setting project. Partnering equally with consumers and clinicians, we aimed to jointly establish the top maternity care research priorities for our region while creating strong collaborations between the two health services, university partners and active healthcare consumers to inform embedded, responsive research to meet local needs.

Methods

The research priority setting process

The JLA research process involved five sequential stages: initiation, consultation, collation, interim ranking, and final priority setting.

Stage 1: initiation

The project was overseen by a steering group of 13 key stakeholders of maternity care services across the two participating hospital and health services (Table 1). The initial steering group meeting members agreed on the scope of the Maternity Care Research Priority Setting Project and developed the harvesting survey for distribution in the consultation stage. The harvesting survey was the first survey developed during the JLA process and was designed to gather, or ‘harvest’, the maternity care research end-user survey respondents’ ideas and suggestions for areas of possible research need.

Table 1.Stakeholder representation in steering group.

Stakeholder representatives	Metro North Health HHS	Sunshine Coast HHS
Clinician researchers employed in the health service	1	1
Consumers/consumer advisors	2	1
Obstetric medical officers	1	1
Midwives	2	2
Perinatal allied health practitioner	1	0
Health service executive leadership	1	0

HHS, hospital health service.

Stage 2: consultation

The harvesting survey developed by the steering group was available via Microsoft Forms between 25 October 2022 and 9 January 2023. The survey weblink and QR code was disseminated to relevant stakeholder groups via posters displayed throughout the two health services’ (inclusive of five maternity units) clinical areas; social media channels; and emails to health service staff.

The survey included demographic questions including which hospital the maternity care was received from, and screening questions to ensure eligibility. Clinicians were asked about their healthcare role and at which hospital they primarily worked. Demographic data were analysed regularly, with additional communications for underrepresented groups subsequently targeted.

Consumer respondents were asked to reflect on their maternity care experience and respond to two free-text questions:

• What areas of maternity care could be further improved?

• What should research focus on in maternity care?

Clinician respondents were asked to reflect on their experience as a maternity care provider and respond to three free-text questions:

• What areas of maternity care could be further improved?

• What areas of maternity care need more evidence to demonstrate the effectiveness of interventions, or areas for de-implementation?

• What are key unanswered questions for maternity care?

The steering group developed these questions with slight wording differences between the consumer and clinician questions to ensure that the experience or expertise of the survey participant was considered.

Survey respondents were invited to provide their email addresses if they were interested in being involved in the subsequent stages.

Stage 3: collation

The consultation stage provided raw research suggestions and questions via the harvesting survey. Responses were compiled and categorised into broad themes by the project team. To retain the integrity of initial submissions some suggestions were mapped to two or more categories. To reduce potential individual bias or misinterpreted categorisation, independent second checks were conducted by members of the project team. The steering group met to further consolidate suggestions within categories, generating ‘indicative questions’ capturing the ideas within each category, and removing duplicate/similar responses. If robust existing evidence was available, questions were subsequently removed.

Stage 4: interim prioritisation

To reduce indicative questions generated during Stage 3, an interim ranking exercise was distributed back to the Maternity Care community (via the same networks and processes used during Stage 2). Survey participants were invited to select up to 10 questions that they felt were most important to be answered by future research. The survey was available online via Microsoft Forms between 10 February and 24 February 2023. Equal weighting was given to each selection, and consumer and clinician ranking was stratified.

Stage 5: final priority setting

The final priority setting stage involved a 1 day (6 h) face-to-face workshop. The workshop used an adapted nominal group technique (NGT) as per the JLA framework. Workshop participants were identified to ensure a broad representation of all end-user maternity care groups. The workshop was divided into five sessions with successive phases of prioritisation, each session building on the one before (Fig. 1).

Fig. 1.

Workshop sessions and final priority setting process.

During session 2 and session 4, breakout groups were provided with question cards (each card outlining one of the 27 shortlisted questions). In recurring order, participants described their top and bottom priorities together with their reasoning. Small group facilitators began arranging question cards into green, yellow and red zones. Questions placed in the green zone were viewed as most important by the group, while those in the red zone were less important. Questions that could not be agreed upon were placed in the yellow zone. By the conclusion of each breakout session, all question cards were ranked for discussion in the following whole group sessions.

Results

The top five research priorities identified by the Maternity Care Priority Setting Project reflect the concerns of women, their support/labour partners and healthcare professionals who provide maternity care in this project’s regions. Method results are summarised and presented in Fig. 2. Participant response rates and characteristics during each priority setting stage are listed in Table 2. A higher proportion of consumer participants responded to the initial survey and clinical researchers to the ranking, however, all groups were represented at varying levels through all stages.

Fig. 2.

Overview of maternity care research priority setting project methods and results.

Discussion

This paper outlines the top five priorities for maternity services research agreed by consumers and clinicians across two large health services in south-east Queensland, Australia. To our knowledge, this is the first time that end-users have successfully partnered to set research priorities for maternity services in Australia.² The process enabled diverse viewpoints to be considered, and for consensus to be generated in a collaborative and rigorous manner. This process should give researchers and funders confidence that research studies aligned with these priorities are positioned to answer questions that are not only important to, but can also positively impact, front-line maternity care.

The differing priorities that consumers and clinicians hold, as influenced by their lived experiences and clinical expertise, are noted, with some discrepancies observed between the priority ranking distributions of these two research end-user groups in the interim ranking stage. However, the degree of consensus between clinicians and consumers on the top research priorities was clear. Both groups independently prioritised research to safely reduce intervention in labour and birth, increase spontaneous vaginal birth rates, and improve the experiences and outcomes of priority population groups. Agreement on the importance of these contemporary issues was maintained throughout the final prioritisation workshop and is reflected in Priorities 1 and 2, as was a fairly consistent representation from the various respondent groups.

The process forged new relationships between researchers, clinicians and maternity consumers. Although early involvement of end-users is often overlooked, realisation of the benefits of end-user involvement is dependent on this continuing through all phases of the research cycle.^5,6 The National Health and Medical Research Council is committed to fostering active and authentic consumer engagement for all health and medical research throughout the entire research cycle.⁸ Health service executive were also invited to participate during each stage of priority setting. This provided an effective feedback loop that allowed for consideration of resource allocation operationally and helped set the top priorities within the health service’s research agenda. Future research should map how these priorities are taken up by researchers, and how end-user involvement is maintained.

Through improved transparency of research priority setting methods, and partnering with consumers and practising clinicians, the acceptability and implementation of the identified research priorities will be strengthened.^5,6,12 Furthermore, research efforts and funding can be invested in generating evidence that is of greatest importance to all stakeholders where studies that have outcomes with greater clinical value can be optimised.^1,12

Conclusion

This project has successfully partnered with research end-users to generate a shared research agenda. Our top five research priorities have been endorsed via a robust and validated process involving local consumers, midwifery, medical, allied health staff and hospital executives, and can confidently be championed as maternity research priorities for the coming years. A modified JLA priority setting framework can be successfully applied within Australian health service settings to identify research priorities. It is a transparent process that strengthens the legitimacy and credibility of research agendas and is replicable across different contexts.