Introduction:
Infant mortality rate, defined as the number of deaths in children under one year of age per 1,000 live births in the same year, has been considered as a general measure of population health (Reidpath & Allotey, 2003). Infant mortality is an important indicator of the health of a nation due to the fact that it is associated with factors such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices (MacDorman, Mathews, Mohangoo, & Zeitlin, 2014). Subsequently, prenatal care plays a significant role in infant mortality due to the fact that infants without prenatal care are five times more likely to die than those that received prenatal care (U.S. Department of Health and Human Services, 2016).
Furthermore, prenatal care is essential to healthier pregnancy outcomes because it monitors the changes in the health of the pregnancy, encourages preventative health, and determines potential risk factors for the mother and fetus (Evans & Lien, 2005). To improve prenatal care, effective and efficient patient provider communication that facilitates adherence to prenatal medical recommendations is essential (Duggan, 2006). Patient provider communication significantly predicts prenatal care satisfaction, which ultimately is a key component in building a long lasting provider-patient relationship (Dahlem, Villarruel, & Ronis, 2015). Thus, making patient provider communication a high priority and a critical issue for U.S. health care organizations (Bergman & Connaughton, 2013).
Purpose:
Although prenatal care and patient provider communication have been studied separately, there is limited research investigating how patient provider communication is related to adherence to prenatal care recommendations using an individual interview approach and a proposed theoretical framework. The purpose of this study was to examine how patient provider communication and other associated factors contribute to adherence to prenatal care recommendations using a mixed methodological approach.
Methods:
A qualitative study using face-to-face interviews was conducted to gain a better understanding of prenatal care and patient provider communication among pregnant women between 18-45 years old in their second or third trimester (N=30). In addition to the individual interviews, a cross-sectional study of pregnant women between the same age range in their second or third trimester of pregnancy (N=401) was conducted. In both studies, the participants were recruited from hospitals, clinics, private doctor’s offices, County Health Department, community agencies, health fairs, and neighborhood clinics in Lucas County, Ohio using flyers posted at the various locations and through referrals from social workers, and hospital, clinic, and health department staff.
Results:
The results in chapter two indicated two salient themes regarding satisfaction emerged: (1) overall quality of the encounter and (2) health care system influences. Within the overall quality of the encounter, factors that influence decision-making and communication practices were two factors that influenced satisfaction with prenatal health care. Within health care system influences, four factors that influenced satisfaction with prenatal health care emerged: (1) continuity of care, (2) referral for resources, (3) information from another source within health care system, and (4) other health care system employee encounters. Results showed that pregnant women adhered to prenatal care recommendations due to preventative measures for their baby and themselves, as well as prior experiences and trust for their primary prenatal health care provider.
The results in chapter three demonstrated a difference in adherence to prenatal care recommendations and demographic, patient provider, and intermediate outcome variables. Patient’s prenatal care motivation and prenatal care shared decision-making accounted for 10% (R2) of variance on adherence to prenatal care recommendations. Patient’s trust in prenatal care provider, patient’s distrust in prenatal care provider, and self care self-efficacy during pregnancy accounted for 5% (R2) of the variance in patient’s prenatal care motivation. An increase in patient’s trust in prenatal care provider is associated with an increase in patient’s prenatal care motivation (ß= .16, p<.05), a decrease in patient’s distrust in prenatal care provider is associated with an increase in patient’s prenatal care motivation (ß= -.12, p<.05), and an increase in and self care self-efficacy during pregnancy is associated with an increase in patient’s prenatal care motivation (ß= .14, p<.05).
Patient’s perceptions of prenatal care provider’s cultural competency, patient’s perception of patient provider interaction, patient’s perceived discrimination, and patient’s prenatal care satisfaction accounted for 30% (R2) of the variance in prenatal care shared decision-making. An increase in patient’s perceptions of prenatal care provider’s cultural competency is associated with an increase in prenatal care shared decision-making (ß= .22, p<.05). In addition, an increase in patient’s perception of patient provider interaction is associated with an increase in prenatal care shared decision-making (ß= .17, p<.05). Furthermore, a decrease in patient’s perceived discrimination is associated with an increase in prenatal care shared decision-making (ß= -.14, p<.05). An increase in patient’s prenatal care satisfaction is also found associated with an increase in prenatal care shared decision-making (ß= .31, p<.05).
Discussion:
Study one contributes to the emerging body of evidence demonstrating that pregnant women adhered to prenatal care recommendations due to preventative measures for their baby and themselves, as well as prior experiences and trust for their primary prenatal care provider. Based on the literature, the researcher hypothesized that communication practices, decision-making, and satisfaction would directly influence adherence to prenatal care recommendations, however, this in fact was not the case. Based on the results, communication practices, decision-making, and satisfaction do not directly influence adherence to prenatal care recommendations. It was determined that communication practices and decision making directly influenced satisfaction, which indirectly influenced adherence to prenatal care recommendations.
However, based on literature, we further explored what influence satisfaction with prenatal care among pregnant women in their second or third trimester of pregnancy. Our study found that satisfaction influence prenatal care via two unique salient themes: (1) overall quality of the encounter and (2) health care system influences. Within the overall quality of the encounter, factors that influence decision-making and communication practices emerged as factors that influence satisfaction.
Our study provides additional evidence to support the fact that decision-making influences satisfaction. Consistent with a previous study (Glass et al., 2012), satisfaction with the overall quality of the health care experience is related to the quality of interaction during decision-making with the health care provider. Furthermore, our study indicated that communication practices influence satisfaction. Consistent with a previous study (Walker, Miller, & Dalton, 2007), the quality of communication between patients and their health care providers affects satisfaction with care in many clinical settings. Although participants were generally satisfied, some participants stated that time could be improved, specifically wait time and time with their primary prenatal health care provider. Participants in our study expressed that health care system influences impacted prenatal care satisfaction due to continuity of care, referral for resources, information from another source within health care system, and other health care system employee encounters. Consistent with another study (Lori, Yi, & Martyn, 2011), women stressed the importance of being able to see the same provider at each of their subsequent prenatal visits.
Study two provides additional evidence to support the fact that patient provider communication variables are positively associated with the adherence to prenatal care recommendations among pregnant women between the ages of 18-45 years old in their second or third trimester. The results from this study demonstrated that there is a relationship between adherence to prenatal care recommendations and various variables. There are statistically significant difference between adherence to prenatal care recommendations and some of the demographic, patient provider communication, and intermediate outcome variables.
Based on the path analysis, prenatal care shared decision-making and patient’s prenatal care motivation predict the outcome variable, adherence to prenatal care recommendations, directly. Consistent with a previous study, (Tessema, Jefferds, Cogswell, & Carlton, 2009), communication between the health care provider and patient serves as a motivator to adhere to prenatal care recommendations. Literature has shown that a common barrier among pregnant women were poor perceived interaction with the health care provider, which ultimately impacted the patient’s motivation to adhere to prenatal care recommendations (Tessema et al., 2009).
In regards to shared decision-making, research has shown that communications with providers influenced women’s decision to engage in prenatal care (McCathern, 2011). Consistent with previous studies, (Glass et al., 2012; McCathern, 2011), shared decision-making is advocated on premises that patients have a right of self-determination, as well as an expectation that patient involvement in shared decision-making can increase the likelihood of treatment adherence. Further, the relationship between shared decision-making is important because patients usually control the extent to which they adhere, thus affecting treatment, health outcomes, and adherence to recommendations (Glass et al., 2012).
Furthermore, based on the path analysis, patient’s trust in prenatal care provider, patient’s distrust in prenatal care provider, and self-care self-efficacy during pregnancy directly predicts patient’s prenatal care motivation. Additionally, based on the path analysis, patient’s trust in prenatal care provider, patient’s distrust in prenatal care provider, and self-care self-efficacy during pregnancy indirectly predicts adherence to prenatal care recommendations. Consistent with a previous study, (Peters, Benkert, Templin, & Cassidy-Bushrow, 2014), patient’s level of trust has been positively correlated with patient’s satisfaction with care, health-seeking behaviors, adherence to medical treatment plans, and adherence to return for follow up appointments. Moreover, distrust of provider has been associated with poorer health status, ultimately due to the lack of adherence (Peters et al., 2014).
Moreover, based on the path analysis, patient’s perceptions of prenatal care provider’s cultural competency, patient’s perception of patient provider interaction, patient’s perceived discrimination, and patient’s prenatal care satisfaction directly predicts prenatal care shared decision-making and indirectly influenced adherence to prenatal care recommendations. Consistent with a previous study, (Like, 2011), cultural competency via understanding the impact of stereotyping can impact decision making.
In regards to patient’s perception of patient provider interaction, consistent with a study (McCathern, 2011), interaction with providers influenced pregnant women’s decision to engage in prenatal care. Research has shown that the ability of a provider to clearly communicate by breaking down important concepts are important factors for patients in regards to decision-making (McCathern, 2011).
Furthermore, patient’s perceived discrimination and prenatal care shared decision-making has yet to be investigated, however, research has shown that racial and ethnic minorities receive differential health care treatments in regards to patient provider communication, thus affect shared decision-making (Meghani et al., 2009). According to Thornton, Powe, Roter, and Cooper (2011), health care providers are more likely to view racial and ethnic minorities as noncompliant or less intelligent than their Caucasian counterparts.
Although, our study demonstrated that patient’s prenatal care satisfaction directly influenced prenatal care shared decision making, studies have shown that that one aspect of satisfaction with a health care experience is the quality of interaction during decision-making with the health care provider (Glass et al., 2012). Thus, satisfaction with the overall health care encounter is linked to shared decision-making (Glass et al., 2012).