The challenge of adopting the health assessment when implementing antenatal and postnatal Group Care: identifying and understanding cross-country modifications and corresponding strategies to enable its adoption: early version

Background: Antenatal and postnatal Group Care, based on the Centering Healthcare model, relies on three core components: health assessment, interactive learning and community building. The health assessment consists of self-assessments conducted by the participants and one-to-one medical check-ups conducted by the healthcare provider. Research shows that this component can be challenging within existing health care systems. This study aimed to investigate the modifications and corresponding strategies applied to adopt the health assessment during Group Care implementation. Methods: A qualitative descriptive study explored modifications to the health assessment and the corresponding strategies in 24 Group Care implementation sites in seven countries. A structured qualitative survey was conducted based on the Expanded Framework for Adaptations and Modifications to Evidence-Based Interventions including views of different stakeholders (site-level and project-level implementers). This provided data on the 'who', 'what', and 'where' of modifications and corresponding strategies. Reflexive thematic analysis provided both structured and in-depth insights into the adaptation process. Results: Three cross-country strategies were identified: (1) creative solutions to find appropriate spaces for Group Care to accommodate the health assessment, (2) providing assistance with self-assessment, (3) and extending the duration of one-to-one medical check-ups. These strategies were primarily the result of joint decisions made by the implementation team, influenced by multiple context-related factors. Different perspectives emerged regarding for whom these strategies were applied, with some stating it as being for the benefit of the participants, while others aimed to align with facilitators' preferences and familiarity with providing routine care. Conclusions: The role of differing perspectives in the adaptation process when implementing Group Care and the challenge for facilitators to align their attitudes, beliefs and skills toward the Group Care model within an individually focused healthcare system, emerged as underlying factors to fully adopt the health assessment. Furthermore, our study demonstrates that, despite the locally context-driven nature of modifications in implementation, it remains valuable to examine them within a cross-country design to identify transferable insights that inform future implementation efforts and implementation science.