Health engagement: a systematic review of tools modifiable for use with vulnerable pregnant women

Jyai Allen, Debra K Creedy, Kyly Mills, Jenny Gamble

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    Objective: To examine available health engagement tools suitable to, or modifiable for, vulnerable pregnant populations. Design: Systematic review. Eligibility criteria: Original studies of tool development and validation related to health engagement, with abstract available in English, published between 2000 and 2022, sampling people receiving outpatient healthcare including pregnant women. Data sources: CINAHL Complete, Medline, EMBASE and PubMed were searched in April 2022. Risk of bias: Study quality was independently assessed by two reviewers using an adapted COSMIN risk of bias quality appraisal checklist. Tools were also mapped against the Synergistic Health Engagement model, which centres on women’s buy-in to maternity care. Included studies: Nineteen studies were included from Canada, Germany, Italy, the Netherlands, Sweden, the UK and the USA. Four tools were used with pregnant populations, two tools with vulnerable non-pregnant populations, six tools measured patient–provider relationship, four measured patient activation, and three tools measured both relationship and activation. Results: Tools that measured engagement in maternity care assessed some of the following constructs: communication or information sharing, woman-centred care, health guidance, shared decision-making, sufficient time, availability, provider attributes, discriminatory or respectful care. None of the maternity engagement tools assessed the key construct of buy-in. While non-maternity health engagement tools measured some elements of buy-in (self-care, feeling hopeful about treatment), other elements (disclosing risks to healthcare providers and acting on health advice), which are significant for vulnerable populations, were rarely measured. Conclusions and implications: Health engagement is hypothesised as the mechanism by which midwifery-led care reduces the risk of perinatal morbidity for vulnerable women. To test this hypothesis, a new assessment tool is required that addresses all the relevant constructs of the Synergistic Health Engagement model, developed for and psychometrically assessed in the target group. PROSPERO registration number: CRD42020214102.
    Original languageEnglish
    Article numbere065720
    Number of pages13
    JournalBMJ Open
    Issue number3
    Early online date10 Mar 2023
    Publication statusPublished - 10 Mar 2023

    Bibliographical note

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:


    • Delivery of Health Care
    • Female
    • Health Personnel
    • Humans
    • Maternal Health Services
    • Maternal medicine
    • Obstetrics
    • Patient Participation
    • Pregnancy
    • Pregnant Women
    • Systematic Review


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