Measuring and Improving Vitamin D awareness and promotion for pre and postnatal women across Greater Manchester 2013The audit findings

Deborah LeeLucy Wilcoxon

Department of Epidemiology

Introduction

First audit took place in 2011 Findings:

poor knowledge very little evidence of promotion of

vitamin D to pre- and postnatal women Number of recommendations made

to participating trusts Awarded further funding in 2012 to

re-audit.

Methodology

Provider services Audit Establish policies, personnel and training

at trust level Staff Survey

Determine knowledge and reported current practice of staff

Case note audit Establish current practice through

documentation in case notes

Standards

Standard1. Midwives and health visitors to receive training on

vitamin D promotion and supplementation 100%2. Pre and postnatal women to undergo a risk

assessment to identify risk factors for vitamin D deficiency

100%3. Pregnant women to be verbally advised of the

importance of vitamin D and suitable supplementation at the booking appointment with the midwife

100%

4. Postnatal women verbally advised on the importance of vitamin D and suitable supplementation at the initial appointment with the health visitor

100%

5. Pre and postnatal women to be given literature containing information on vitamin D 100%

Participating trustsRepeating trusts (2011 & 2013)

New trusts (2013)

Midwifery

Wrightington, Wigan and Leigh NHS FT (survey only in 2011)

University Hospital of South Manchester NHS FT

Stockport NHS FTRoyal Bolton NHS FT (survey only in 2011)Central Manchester NHS FT

Health Visiting

NHS Manchester NHS BoltonNHS BridgewaterNHS StockportNHS Salford

Provider services audit

TrustPolicy

in placeTeam/

coordinator in place

In-house leaflet

Information

distributed

Training provided

Midwifery

Central Manchester FT* Stockport FT* Royal Bolton FT South Manchester FT Wrightington, Wigan and Leigh FT*

Health visiting

NHS Bolton NHS Bridgewater NHS Manchester* NHS Salford NHS Stockport

= Improvements made since 2011

*Repeating trusts

Staff Survey – response rateResponse Rate:A total of 237 midwives and 121 health visitors from 10 healthcare providers participated in the survey.

This give an overall response rate of 22% for Midwives 20% for Health Visitors

Response rates ranged from 9% to 83% at individual Trusts

Staff Survey - Vitamin D Knowledge Staff knowledge of vitamin D was relatively poor.

RDA 5 food sources

Percentage obtained

from the sun

Minerals it helps the body to absorb

3 main roles within the

body

Risk factors/ symptoms of

deficiency

0%10%20%30%40%50%60%70%80%90%

100%

73%

26%

38%

50%

13%22%

53%

26% 30%

63%

23%16%

Midwives

Perc

enta

ge o

f sta

ff

p <0.001

p <0.05

p <0.05

Training Rates

Trust

Percentage attended vitamin D training within the last year

Central Manchester NHS FT 6%Stockport NHS FT 20%University Hospital South Manchester NHS FT 17%Royal Bolton NHS FT 17%Wrightington, Wigan and Leigh NHS FT 24%TOTAL Midwives 14%NHS Bolton 38%NHS Bridgewater 42%NHS Manchester 93%NHS Salford 53%NHS Stockport 36%TOTAL Health Visitors 47%

Staff Survey - Vitamin D Training and Knowledge

0%10%20%30%40%50%60%70%80%90%

100%

73%

25%35%

60%

23% 20%

72%

30%39%

59%

16%22%

Trained Staff Untrained Staff

Perc

enta

ge o

f Sta

ff

Staff Survey – Vitamin D PracticeVitamin D Practice:

Report discussing vitamin D with 'all' or 'most' of their clients

Report feeling 'very confident' or 'confident in discussing vitamin D

with clients

0%10%20%30%40%50%60%70%80%90%

100%

53%40%

65%56%

MidwivesHealth Visitors

Perc

enta

ge o

f Sta

ff

Main reason for not discussing with ‘all’ clients: MW – a lack of risk factors presented by the client (28%) HV – lack of training or confidence (33%)

p <0.05

p <0.001

Staff Survey – Practice and Training

0%10%20%30%40%50%60%70%80%90%

100%

77%63%65%

44%Trained StaffUntrained Staff

Main reason for not discussing with ‘all’ clients: Trained staff– lack of knowledge/confidence (29%) Untrained staff – lack of risk factors presented (32%)

p <0.05 p <0.001

Staff Survey – Healthy Start Scheme Healthy Start scheme - vouchers exchanged for

vitamin supplements

72% of HV discuss Healthy Start with ‘all’ or ‘most’ of their clients, compared to 43% of MW.

69% of trained staff discuss Healthy Start with ‘all’ or ‘most’ of clients compared to 52% of untrained staff

Client not considered eligible - most common reason for not discussing the Healthy Start Scheme.

Comparison of repeated Trusts

Trusts that took part in the staff survey for both 2011 audit and the 2012/2013: Midwifery:▪ Central Manchester NHS Foundation Trust▪ Royal Bolton Hospital NHS Foundation Trust▪ Stockport NHS Foundation Trust▪ Wrightington, Wigan and Leigh NHS

Foundation Trust Health Visiting:▪ NHS Manchester

Comparison of repeated Trusts

RDA

Food

sou

rces

Perc

enta

ge o

b-ta

ined

from

the

su

n

Risk

fact

ors/

sym

p-to

ms

of d

efici

ency

Dis

cuss

‘all’

or

‘mos

t’ c

lient

s

Feel

‘ver

y co

n-fid

ent’

or

'con

-fid

ent'

whe

n di

scus

sing

wit

h cl

ient

s

Vitamin D knowledge Vitamin D Practice

0%10%20%30%40%50%60%70%80%90%

100%

39%

8%14%

8%

22%13%

68%

30%

43%

23%

52%41%

2011 2013

Perc

enta

ge o

f St

aff

p <0.001

p <0.001

p <0.001

p <0.001

Data from responses to knowledge and practice questions across Trusts who participated in both the 2011 and 2013 audit.

p <0.001

p <0.001

Summary of staff survey Knowledge is relatively poor and is not

shown to improve through recent training. HV and trained staff discuss Vitamin D

and Healthy Start more with ‘all’ or ‘most’ clients and feel more confident in doing so.

Overall, Trusts who participated in the 2011 audit improved in both their vitamin D knowledge and practice in 2013.

Case note audit - sampling

Requested sample of 100 pre/postnatal women per trust

Sample to be selected from women who gave birth between Oct 2011 and Mar 2012

However, miscommunication led to women being sampled from bigger cohort – Jan 2011 and Jan 2013

Case note audit - SampleTrust n Average

age of sample

Prenatal

Central Manchester NHS FT 102 29Stockport NHS FT 96 29Royal Bolton NHS FT 84 27University Hospital South Manchester NHS FT

100 30

Wrightington, Wigan and Leigh NHS FT 100 27TOTAL 482 28

Postnatal

NHS Bolton 106 28NHS Bridgewater 104 30NHS Manchester 28 30NHS Salford 97 29NHS Stockport 73 31TOTAL 408 29

Evidence of verbal/written vitamin D information given to all women

Cent

ral M

anch

este

r

Stoc

kpor

t

Roy

al B

olto

n

Sout

h M

anch

este

r

Wri

ghti

ngto

n, W

igan

and

Lei

gh

NH

S Bo

lton

NH

S Br

idge

wat

er

NH

S M

anch

este

r

NH

S Sa

ford

NH

S St

ockp

ort

prenatal postnatal

0%20%40%60%80%

100%

Evidence of vitamin D discussed (%)

Evidence of risk factors

Risk factors: Ethnicity: women of South Asian, African,

Caribbean or Middle Eastern descent Medical: personal/family history of bone

disorders, coeliac disease, Crohns disease, bone deformity, multiparity (short spacing between pregnancies)

BMI: women with a BMI of 30 or above at booking (prenatal only)

Breastfeeding: women who are exclusively breastfeeding (postnatal only)

Evidence of at least one risk factorCe

ntra

l Man

ches

ter

Stoc

kpor

t

Roya

l Bol

ton

Sout

h Ma

nche

ster

Wrig

htin

gton

, Wig

an a

nd Le

igh

NHS

Bolto

n

NHS

Brid

gewa

ter

NHS

Manc

hest

er

NHS

Safo

rd

NHS

Stoc

kpor

t

prenatal postnatal

0%10%20%30%40%50%60%70%80%90%

100%

83%

22%30% 33%

20%

51%

38%

79%

32%

51%

Evidence of vitamin D information given to those identified as having a further risk factor for vitamin D deficiencyCe

ntra

l Man

ches

ter

Stoc

kpor

t

Roya

l Bol

ton

Sout

h M

anch

este

r

Wri

ghti

ngto

n, W

igan

an

d Le

igh

NH

S Bo

lton

NH

S Br

idge

wat

er

NH

S M

anch

este

r

NH

S Sa

ford

NH

S St

ockp

ort

prenatal postnatal

0%10%20%30%40%50%60%70%80%90%

100%

80% 81%

28%

91% 90%

17%

35%

50%

87%76%

Comparison of 2011 and 2013 audit

3 trusts participated in both 2011 and 2013 case note audits: Midwifery▪ Central Manchester FT▪ Stockport FT

Health visiting▪ NHS Manchester

Comparison of 2011 and 2013 audit

No significant differences between the samples for age and ethnicity

No significant differences in the number of risk factors except for BMI – large increase at CMFT (26% 74%)

Comparison of 2011 and 2013 audit

0%20%40%60%80%

100%

17%

59% 63%42% 39%

74%

20112013

p <0.05

p <0.001

p <0.001

Summary of case note audit Some trusts performing better than others. Evidence of 65% receiving some form of

information Evidence for at least one risk factor of

vitamin D deficiency present in 41%... …of which 62% received some form of info Those who repeated the audit appear to

have made significant improvements to practice.

Standards achieved

Standard 1: 100% midwives and health visitors to receive training on vitamin D promotion and supplementation.Standard 2: 100% Pre and postnatal women to undergo a risk assessment to identify risk factors for vitamin D deficiencyStandard 3: 100% of pregnant women verbally advised on the importance of vitamin D and suitable supplementation at the booking appointment.Standard 4: 100% of postnatal women verbally advised on the importance of vitamin D and suitable supplementation at the initial appointment.Standard 5: 100% of women to be given literature relating to the importance of vitamin D and suitable supplementation for pre and postnatal women.

Limitations Poor response rate for staff survey – may not

be representative Women sampled from bigger than requested

cohort for the casenote audit (2011-2013 rather than Oct 2011 – Mar 2012)

Possibility of inaccurate documentation Evidence of written info given not clear Training – frequency and level of training

unclear

Conclusion Standards not achieved – all women to

receive verbal and written information on vitamin D

Even those at a greater risk do not always receive verbal/written information

Whilst each of the risk factors are routinely assessed, they are not being linked to vitamin D deficiency

However, policy and practice improvements have been made in trusts repeating audit.

Recommendations

1. Documentation of verbal and written literature on vitamin D required in all case notes

2. Training programmes to be rolled out to all staff

3. Routine assessment – women with risk factors need to be flagged up.

4. Women with further risk factors to be offered further screening for vitamin D deficiency???

Thank you

Any questions?