Health Personnel

To ensure generalizability and ability to extrapolate the results of JECS to Japanese population, the 15 Regional Centers are selected to cover wide geographical areas. The study locations’ urbanization and land development are diverse, from urban and suburban to rural areas as well as from agricultural and fishery to commercial and industrial uses.
Regional Centers were selected in a competitive process in which universities and other research institutions were invited to submit proposals for covered areas and population, recruitment methods, organization structures, regional liaison, and the resources. Each Regional Center consists of one or more study areas. The population of the selected study areas is 130,000 to 600,000. Assuming birth rate of the study areas to be 1%, each Regional Center will see 1,300 to 6,000 annual births, 4,400 on average. JECS aims half of all the births in the area to be covered. Selected Regional Centers are required to recruit 3,000 to 9,000 pregnant women in three years, totaling to 100,000 participants in 15 Regional Centers (Figure 1). In order to ensure the maximum contact with eligible participants, Regional Centers have formed JECS regional liaison involving local governments and health care providers. All the study areas are contained within administrative units, e.g. municipalities, further enhancing local government cooperation. This makes it easier to obtain basic health statistics in the study areas, for example, total number of births, sex ratios, birth weights, morbidities, and mortalities. It also helps us maximize follow-up and retention rates.

Details of the JECS concept and design have been published elsewhere.^{3 (link)} Briefly, JECS is funded directly by Japan’s Ministry of the Environment and involves collaboration between the Programme Office (National Institute for Environmental Studies), the Medical Support Centre (National Centre for Child Health and Development), and 15 Regional Centres (Hokkaido, Miyagi, Fukushima, Chiba, Kanagawa, Koshin, Toyama, Aichi, Kyoto, Osaka, Hyogo, Tottori, Kochi, Fukuoka, and South Kyushu/Okinawa). Each Regional Centre determined its own study area, consisting of one or more local administrative units (cities, towns or villages) (eTable 1), and was responsible for recruiting women in early pregnancy who resided in its study area. Between January 2011 and March 2014, we contacted pregnant women via cooperating health care providers and/or local government offices issuing Maternal and Child Health Handbooks and registered those willing to participate. The women’s partners (fathers) were also approached, whenever possible, and encouraged to participate. Several Regional Centres later expanded their study areas, because they learned that significant numbers of women residing in adjacent areas gave birth at cooperating health care providers. The Fukushima Centre’s study area was expanded to include the whole of Fukushima Prefecture because of concerns over the effects on health of radioactive fallout from the Fukushima Daiichi Nuclear Power Plant after the March 2011 earthquake and tsunami.

Two pairs in the research team (one neonatologist and one paediatrician in the first pair, one paediatrician and one general physician in the other pair) analysed the relevance of the identified problems and actions taken based on facilitators’ diaries from the 52 facilities. The independent scoring of each analyst was discussed to reach a consensus. A maximum score of 22 points could be obtained in the knowledge assessment (1 point for each correctly answered question). Baseline and endline results were compared across levels of the health systems (commune health centres and hospitals) and categories of health workers (physician, midwife and nurse). Data from the antenatal care observations were compared before and after the 12 months of PeriKIP intervention. Data from knowledge assessment and observations were entered using EpiData (version 3.1) and analysed in SAS (version 9.4). Descriptive statistics included proportions, means with 95% confidence intervals and t-tests with p-values.
The qualitative data were transcribed verbatim, translated into English and analysed by content analysis with both inductive and deductive features [45 (link)]. First, each interview of each type (midwives, village health workers, PeriKIP groups at hospitals, facilitators) was read several times to get a naïve understanding. This step informed the decision to approach the material as one data set. After that, open coding was undertaken. Codes were written in the margin of each interview describing aspects of the content. Codes were sorted into sub-categories; thereafter, sub-categories were sorted under categories, and finally, categories were placed under four main categories, i.e. the i-PARIHS dimensions (Innovation, Recipients, Facilitation and Context). One relevant category, Gaining knowledge and insights, as identified in the qualitative analysis, could not be sorted under the i-PARIHS dimensions. This category is presented together with the study outcomes.

The study population consisted of all the medical and nursing healthcare providers involved in providing institutional care during labour and birthing, including obstetric Consultants, Senior Residents, Post- Graduate doctors and all grades of nursing Staff.
Sampling involved "Universal total population sampling” [41 ] whereby all individuals belonging to the study population and present at the time of the study were approached for participation by sharing the Study Participant Information Sheet (Additional file, Annexure 1). This was done to eliminate any selection bias or sampling error. Those healthcare providers who expressed willingness to participate were given the Consent Form (Additional file, Annexure 2) for signature. These respondents were then handed over a printed questionnaire with a request to enter their response. Filled response sheets, along with consent forms, were personally collected from the participants. Since the PI was an Undergraduate student, her involvement in the interview and data collection could not have placed the participants under any coercion.. Of 115 doctors, 96 completed the questionnaire (response rate of 83%), while 55 of 105 nurses completed the questionnaire (response rates of 52%). With a sample of 151, our overall response rate was 69%. Most (95%) of the respondents were females.