Identifying health literacy solutions for pregnant women and mothers in Tasmania: a codesign study

Abstract

Background

Pregnancy and early motherhood offer a crucial period for health literacy development and improve the health of women and future generations. Interventions to support health literacy development during these critical periods are scarce. Existing interventions are rarely informed by health literacy measurement and lack codesign principles.

Aims

To codesign health literacy solutions for pregnant women and mothers in Tasmania, Australia with stakeholders working in maternal and child health services across Tasmania; and to develop a set of recommendations to guide the implementation of identified solutions in the Tasmanian context.

Methods

Qualitative codesign workshops were conducted online (two rounds of workshops distributed across seven occasions). Stakeholders across Tasmania were recruited using purposive sampling. Data were analysed inductively using reflexive thematic analysis.

Results

33 solutions across six themes were generated based on ideas grounded in local knowledge and expertise. The solutions were diverse and most targeted at policy and practitioner levels. Four recommendations with 20 supporting ideas were generated to guide the implementation of the codesigned solutions in Tasmania.

Discussion

The solutions encourage policymakers to carefully consider the health literacy needs of pregnant women and mothers and support effective engagement of relevant stakeholders in planning and designing fit-for-purpose health literacy solutions.

Keywords:

• Health literacy
• codesign
• Ophelia
• pregnancy
• maternal health

Introduction

Health literacy is a critical determinant of health that can empower individuals and communities to enhance control over their health and improve health outcomes for themselves and the people around them (World Health Organisation, 2016). Health literacy is a multifaceted concept that promotes the use of a strength-based and solution-oriented approach to improve health outcomes and reduce health inequity (Osborne et al., 2022).

Health literacy is broadly defined as “the personal characteristics and social resources that influence the ability of individuals and communities to access, understand, appraise, remember, apply and use information, knowledge and services to make decisions to promote health and sustain healthy behaviour” (World Health Organisation, 2015). More recently, health literacy has been acknowledged as a broader concept than an individual’s assets. The broader concept of health literacy recognises the interactivity between an individual and the services they seek to access and is referred to as health literacy responsiveness (Trezona et al., 2017). Health literacy responsiveness provides insights into the ways in which services, organisations and health systems respond to the health needs of individuals and communities to improve health and promote health equity (World Health Organisation, 2022). The World Health Organisation (WHO) is focused on health literacy development at the individual, community and health system levels to accelerate the prevention of non-communicable diseases (NCDs) and improve health and equity outcomes (World Health Organisation, 2022).

Previously thought to be conditions associated mostly with ageing, NCDs now affect people of all ages. Growing evidence suggest that women’s health and lifestyle choices before, during, and after pregnancy can influence their and their children’s risk of developing an NCD in the future (Kapur, 2015; Kapur & Hod, 2020). Pregnancy and the postpartum period offer a unique life course perspective and a convenient window to address future risk of NCDs and their risk factors (tobacco use, harmful alcohol use, physical inactivity and unhealthy diet), reveal underlying conditions and provide support to improve the overall health of women and their children (Firoz et al., 2018; Olander et al., 2018). These crucial life stages demand additional skills and support due to numerous physical, emotional and hormonal changes (Firoz et al., 2018; Javadifar et al., 2016) and the sudden influx of a plethora of information women may receive to achieve optimal health outcomes for themselves and their children (Song et al., 2012). A greater consideration to support health literacy development during this period will play a crucial role in strengthening and achieving equitable maternal and child health outcomes and reduce the future perpetuation of the intergenerational NCDs crisis.

Health literacy interventions to support and enable pregnant women and mothers to engage in healthy lifestyle practices are scarce (Nawabi et al., 2021; Zibellini et al., 2021). Additionally, existing interventions are rarely informed by health literacy theory and measurements (Zibellini et al., 2021), lack codesign principles and do not address the health literacy needs of pregnant women and mothers during intervention development (Melwani et al., 2022). The use of codesign principles promotes the engagement of both the providers and consumers during the development of solutions to ensure that solutions are locally relevant and meet the needs of all relevant stakeholders (Consumer Health Forum of Australia, 2017). Due to the involvement of the end user, the solutions developed using a codesign approach are more likely to be adopted and sustained (Sanders & Stappers, 2008).

The WHO (World Health Organisation, 2022) promotes using an codesign process like Ophelia (Optimizing Health Literacy and Access) to co-create health literacy solutions with diverse stakeholders. This process commences with determining the health literacy needs of the target population using the health literacy questionnaire (HLQ) (Batterham et al., 2014). The Ophelia process uses data-informed vignettes (case studies produced from the HLQ data) to represent and communicate the health literacy needs of the target population. The systematic application of the Ophelia process has led to the successful co-creation of ideas to enhance the health literacy responsiveness of the health services participating in the Ophelia process (Aaby et al., 2020; Anwar et al., 2021; Beauchamp et al., 2017; 2020; Cheng et al., 2020; Jessup et al., 2018). The use of a codesign approach like Ophelia in maternal and child health sector may enhance the health literacy responsiveness of these services in Australia and globally.

At the commencement of this research, the Ophelia process had not been used to codesign solutions for pregnant women and mothers in Australia or globally. However, more recently, the Health Literacy in Pregnancy (HeLP) study in Denmark is using the Ophelia process to understand the health literacy needs of pregnant women attending antenatal care and subsequently codesign health literacy responsive interventions (Meldgaard et al., 2022). The Danish study is currently underway with results yet to be published. However, as health literacy is context-specific, the findings from the Danish study may not be responsive to the health needs of women in the Australian context. Therefore, highlighting a need for meaningful codesign of health literacy solutions for the target population in Australia.

Tasmania is an island state in Australia and is classified completely as regional and/or rural (Australian Bureau of Statistics, 2021). People in Tasmania face greater socio-economic disadvantages and some of the poor health outcomes than Australia overall (Tasmanian Government Department of Health, 2022). Further, NCD risk factors such as tobacco smoking, unhealthy diet, physical inactivity, and obesity are significant issues in Tasmania (Tasmanian Government Department of Health, 2022). For example, the rate of obesity among adult Tasmanian women has increased from 18.4% in 2009 to 29.3% in 2019 (Tasmanian Government Department of Health, 2020). The greater socioeconomic disadvantage and the significant burden of the NCD(s) risk factors in Tasmania make women and their children more susceptible to developing NCD(s) in future.

In recognition of the significant health challenges experienced by women in Tasmania, this study aims to codesign health literacy solutions for pregnant women and mothers in Tasmania, Australia with various stakeholders working in maternal and child health and the early years services across Tasmania. In addition, it aims to develop a set of recommendations to guide the implementation of the identified solutions in the Tasmanian context. This study is a part of a larger program of work, as such the health literacy needs of the target population have already been assessed using the HLQ (Melwani et al., 2023). The understanding of health literacy needs was further enhanced by the qualitative interviews with the subset of participants of the HLQ survey. The qualitative interviews also explored the knowledge and beliefs of pregnant women and mothers about the impact of NCDs and associated risk factors on their health and their child(s) health. The findings from the qualitative interviews are currently under consideration for publication elsewhere. The findings from each of the phases of the larger project are summarised in Figure 1.

Figure 1. Summary of key findings from each phase of the larger project.

Methods

This research includes the final two phases (Phase 4 and Phase 5) of a larger program of work. As shown in Figure 1, findings from Phase 1 (HLQ survey) and Phase 2 (interviews) informed the cluster analysis and vignette development during Phase 3. The findings from Phase 3 were used to facilitate discussion during the qualitative online workshops (Hansen, 2006) during the final two phases presented in this study.

The project received ethics approval from the Tasmania Health and Medical Human Research Ethics Committee (Ethics approval number H0023036). All participants were required to read an information sheet and give electronic consent prior to admission to the workshops.

Study participants and recruitment

Various stakeholders (public health professionals, healthcare providers, managers, and allied health professionals) working in maternal and child health and early years sectors across Tasmania were recruited using purposive and snowball sampling (Liamputtong, 2013). The stakeholders were recruited via hospitals (Royal Hobart Hospital, Launceston General Hospital and North-Western Regional Hospital), Tasmanian health literacy network, the Tasmanian Health Department (mainly public health services) and through the research team’s existing professional networks. These stakeholders were targeted because of their interest in the study project and experience of working in maternal and child healthcare and early childhood development. All the potential stakeholders were sent an email from the research team which included brief information about this study and a form to register their interest to participate in the codesign workshops. Following the initial email, the research team contacted the potential stakeholders who registered their interest and shared the information sheet and consent form. The research team encouraged potential stakeholders to share the workshop information with their professional network to further enhance the participation. At the end of the Phase 4 workshops, information about the Phase 5 workshops were shared with the participating stakeholders to encourage their participation in the Phase 5 workshops.

Data collection

Consistent with the Ophelia process (Batterham et al., 2014), codesign workshops were used to collect data. The workshops were conducted online via video conferencing software Zoom (Zoom Video Communications Inc).

Phase 4 workshops (one workshop held on four occasions) focused on collectively generating ideas and solutions to respond to the health literacy needs of pregnant women and mothers with young children in Tasmania. The workshop started with an introduction to the project and an overview of the HLQ survey results from Phase 1 of the project (Melwani et al., 2023). Following that, data-informed vignettes (see supplementary file for example) generated from the cluster analysis of the HLQ data and interview data representing the health literacy strengths and challenges of the target population were presented. The following four questions (Beauchamp et al., 2017) were presented to generate discussion to identify local solutions to respond to the needs of the pregnant women and/or mothers personified in the vignette(s). The four questions were:

1. Do you recognise people like this in your community?

2. What stands out to you as important strengths/problems?

3. What things do you think would help?

4. What can health services and communities do to help people like the person in this vignette?

Phase 5 workshops (one workshop held on three occasions) were conducted two months after the Phase 4 workshops to allow time for the collation and synthesis of the Phase 4 ideas and solutions. The codesigned solutions generated in the Phase 4 workshops were presented during Phase 5 workshops and stakeholders were invited to collectively develop a set of recommendations to guide the implementation of the codesigned solutions in the Tasmanian context.

The participants were encouraged to turn on their microphones and use the chat box function to facilitate discussion and share more ideas during the workshop. Both Phase 4 and Phase 5 workshops were digitally recorded after obtaining verbal consent from the workshop participants. All workshops were conducted by SM. The workshops were co-facilitated by RN and/or one researcher intern (GM) whenever necessary. The facilitator and co-facilitator(s) made observational notes throughout and at the conclusion of each workshop.

Data analysis

The workshop data (audio recordings and chat box) were transcribed verbatim. These were combined with the researchers’ observational notes. At this stage, all the participants were deidentified and were allocated a pseudonym. Reflexive thematic analysis was employed using an inductive approach to analyse the transcribed data (Braun & Clarke, 2006). As outlined by Braun and Clarke (Braun & Clarke, 2021), six phases of reflexive thematic analysis were employed: data familiarisation; generating initial codes; generating initial themes; developing and reviewing themes; refining, defining and naming themes and writing the report.

The data analysis was conducted by SM. The data familiarisation was achieved during the transcription of the workshop data, listening to the audio recording and re-reading of the transcripts. The notes (highlighting the necessary information on each transcript) were created using the comment feature on the MS Word. The notes were transferred to MS Excel and were further explored to generate initial codes. The codes were iteratively refined to develop solution and recommendations. The solutions and recommendation were discussed with RN and were grouped to generate initial themes (strategies).The initially generated strategies (themes) and associated solutions and the recommendations to guide the implementation of solutions were shared and discussed with the research team for further refinement and to develop final themes and associated solutions and recommendations. Consistent with the Ophelia process, the final generated solutions were further categorised into four levels: individual, family/community, practitioner and policy levels (Batterham et al., 2014). Following that, the final solutions and recommendations were shared with the workshop participants for further refinement and validation. This collaborative refinement and validation with the research team and participating stakeholders helped to ensure the validity, integrity and trustworthiness of the data analysis process (O’Connor & Joffe, 2020).

Results

Fifteen stakeholders participated during Phase 4 workshops and eight stakeholders participated during Phase 5 workshops. The participating stakeholders represented multiple sectors including the Department of Health, the Department of Education, and Academia as shown in Table 1. The occupation of the participating stakeholders included but were not limited to community dietician, health policy officer, academic lecturer, health literacy officer, university researcher and paediatrician.

Table 1. Departments/organisations represented by participating stakeholders.

Department or Organisation	Number of stakeholders
Phase 4 Workshops
Public Health Services, Department of Health	6
University of Tasmania	2
Child and Family Learning Centres, Department of Education	2
Tasmanian Council of Social Services	1
Royal Hobart Hospital, Department of Health	1
Neighbourhood Houses Tasmania	1
26 TEN Tasmania*	1
B4 Early Years Coalition, Department of Education**	1
Phase 5 Workshops
Public Health Services, Department of Health	5
Royal Hobart Hospital, Department of Health	1
University of Tasmania	1
Neighbourhood Houses Tasmania	1

*26TEN is a network of organisations and individuals working together to improve adult literacy and numeracy in Tasmania.

**B4 Early Years Coalition (B4) is a movement for change to ensure every child in Tasmania is cared for and nurtured through the early years.

During Phase 4, pregnant women and/or mothers personified in the vignettes (five vignettes) were well recognised as someone familiar to workshop participants which helped in facilitating engaging discussions at all workshops.

“I’ve seen the difficulty getting enough time to exercise and plan meals, I hate this, I feel like this cluster [vignette] is pretty typical of my neighbourhood” (P1-W1).

The major barriers/challenges identified by the participating stakeholders were categorised into four categories: individual level (e.g., lack of time and motivation), family and social level (e.g., lack of social and family support), health system level (e.g., inconsistency in health information and health services provision) and societal and cultural level (e.g., unrealistic expectations around motherhood) as shown in Figure 2.

Figure 2. Categorisation of barriers identified by the stakeholders during Phase 4 workshops.

Codesigned solutions

To respond to the health literacy needs identified in the vignettes, 33 solutions across six themes (strategies) were generated from the thematic analysis. The six strategies (with supporting quotes) and associated solutions are shown in Table 2. The six strategies may collectively support the development of a health literacy responsive environment in Tasmania (see Figure 3). Each strategy is described in brief below.

Figure 3. Codesigned strategies (Phase 4) to support the development of health literacy responsive environment in Tasmania.

Table 2. Phase 4. Codesigned strategies and associated solutions from stakeholder consideration of vignettes during ideas generation workshops.

Strategies (and supporting quotes)	Solutions	Implementation level
		Policy	Practitioner	Community/family	Individual
Provide access to locally relevant and context-specific evidence-based health information. “One of the things that we find is that people would really like to have some publicly available list of all the services in an area. So, what are the speech therapists? So, what are the physiotherapists and what do they wait times like? They could go online and go, oh, look, there’s a speech therapist. The wait time is six months. The wait time is three months, then I would know who to ring or actually who they are, because people often just don’t know where those services actually are” (P7-W1) “About having a local hub, whether that’s the GP or whether it’s a Child and Family centre or some other kind of service provision hub where people can go, they can they can use the technology there for their telehealth connection with the specialist, but they also have access to high quality information, whether it’s online on videos or printed information that they can take away, and people who are there to bounce ideas off and connect them with other services or other provision options” (P12-W1) “But there’s no central spot you seem to be able to go to for any of these services too. It’d be great, wouldn’t it, if there was a spot that you could go to and say, “yes, this is aged care, dental needs, mental health, this is where you go, and you know you’re going to get the correct answers “(P13-W1)	Develop a central information portal (or explore existing information portals and tailor them) for pregnant women and mothers in Tasmania to access locally relevant health information. Ensure the quality and consistency of the information shared within the portal. (E.g., Little Tasmanian Website can be used as the central information portal and can guide mothers to access trustful sources of information to support their decision making)
	Create local health information hubs for pregnant women and mothers and integrate them with existing services (e.g., Child Health and Parenting Services (CHAPs), Child and Family Learning Centres, Community centres, Neighbourhood houses) in Tasmania.
	Create a maternal health help line facilitated by healthcare providers to provide women with timely access to credible health resources. (e.g., similar to Get Healthy in Pregnancy program by New South Wales government)
	Provide a regularly updated list of available health and community services for women about available services and where/how to access those services. In addition, provide information about alternative services available. This can be achieved by partnering with existing services such as FindHelp Tas and add a pregnancy and motherhood sub search category.
	Train health connectors/mediators (new and existing) to support women to navigate health system and access appropriate information and services (social, health and community services).
	Educate women about NCDs and other issues related to pregnancy such gestational diabetes, gestational weight gain, preeclampsia, post-partum anxiety/ depression, foetal alcohol spectrum disorders and iodine deficiency and provide them with support to mitigate potential future impacts on their own health and their child/ren’s health. However, it is important to ensure that the information is delivered in a non-judgemental manner and does not create more stigma and guilt.
Provide effective resources and adapt communication to respond to diversity and meet the needs of all women. “Some really good evidence based, weight neutral resources so that people don’t feel judged like this woman (represented in the vignette). If she’s going to read a lot about her risk of diabetes because she’s gaining weight and she has an increased risk of developing type two diabetes already, she’s feeling probably a bit down about that” (P1-W1) “I can definitely see, like for GP’s and whatever, using medical jargon, people not understanding, there are definitely things you can put in place there about teaching there, within the curriculum and the professional development, about Teach Back and checking, understanding and delivering information in different ways and all that sort of thing. So, there are lots of ways that you can sort of address some of those things” (P5-W1)	Provide health information in multiple formats (audio, video, infographics, print, diagram, etc.) and multiple languages depending on the context and needs of mothers. Ensure that the information is codesigned with pregnant women and mothers and other relevant stakeholders to address the needs of end users.
	Develop visual and engaging resources to enhance the understanding of information provided.
	Create weight neutral and non-judgemental resources to engage mothers in healthy lifestyle practices and reduce stigma related to weight gain during and after pregnancy.
	Encourage health providers to communicate in plain language free of medical jargon to ensure shared information is easy to understand for women irrespective of their educational backgrounds. Implement teach-back method to ensure women have understood the information shared with them.
Build the capacity of the health system and health providers to respond to the diverse needs and preferences of women. “I think just maybe supporting the GP’s as well around how they can support people just in their empathy for people, their listening skills, maybe using some motivational interviewing techniques so that people don’t walk away feeling judged, but they walk away feeling listened to and are more likely to come back and engage with their service providers and trust their thoughts on things” (P1-W1) “Need for medical students to be exposed to the general population and just learn those baseline communication skills with the diversity of people using simple, accessible language. And that’s not dumbing down the message, that’s giving the message, giving the information, but in a form and a context that, you know, that person has been able to capture and will be able to then use” (P9-W1) “I think it was Western Australia, where they sent… It’s a regular text message service that’s sent to women during pregnancy. Like, there’s reminders around like “have you booked your appointment?” or “have you taken your iodine?” or “how are you going tonight?” or “have you got a problem?”. So, those sorts of prompts that can come into your phone. Just to remind people so the person doesn’t have to actively engage or go online” (P14-W1)	Build the capacity of health providers to communicate, empathise, listen and respond to the health and other broader needs of mothers. Health providers should not make assumptions and should treat every woman equally and with dignity regardless of their occupation and socio-economic background.
	Train new and existing healthcare providers to effectively use digital technology and telehealth to overcome barriers such as transport and time and enhance self-management for women. However, it is important to consider barriers associated with telehealth such access to technology, data and digital literacy.
	Support primary healthcare teams to partner with and collaborate across existing local early years services and support networks such as CHAPs, and Child and Family Learning Centres in Tasmania. Recognise these services as local hubs to guide and support people to access information and telehealth services.
	Make health appointment system more responsive to the needs of women. If the service or appointment has long wait times or if it is not available, alternative options should be suggested or a reminder should be sent for later appointments.
	Send automatic reminders using SMS, emails or phone calls from health system during and after pregnancy to enhance self-management. This should be especially implemented for enhancing self-management of gestational diabetes.
	*Implement optional group sessions to overcome long wait times for specialist services (e.g., postnatal depression support groups, follow up for gestational diabetes, child health appointments, vaccination clinics). Some of these may already exist but may have been impacted due to COVID.
Provide a tailored, integrated and multidisciplinary approach to maternal and child healthcare. “I was going to say something similar in terms of the set-up of a place like ours, which is a big thing to integrate into service delivery and community houses have lots of different people coming to offer services in the same space. So, for a parent, a pregnant parent with some health issues being able to come to a space where maybe she can talk to that diabetes community nurse or specialist or whoever they are and talk to other parents who have gathered. And then that way she’s changed that. That’s what we see here. So, they feel better for having spoken to some of the parents. They can see their health specialist or support worker in the same place. That ticks a lot of boxes at once” (P4-W1) “You know, can the GP and the specialist work together more closely so that the GP could do some of the more like the testing and things that needs to happen as part of those gestational diabetes appointment services, then having the tele telehealth option to then meet with the specialist and they have that information. Um, yeah, I think that that could be something that, um, the service level could look at to make things a bit easier” (P2-W1) “These issues aren’t new, some of them are new, but her (woman represented in the vignette) mental health and her asthma, but there’s a few things that would have already been happening at the birth and at that time some supports or some awareness or some information or some connections could have been made. So, attaching things that child health care that happens with the check-ups and the vaccinations” (P15-W1)	Integrate antenatal and postnatal care with specialist health services and allied health services so that women can gain timely access to essential services such as endocrinologists, dieticians, physiotherapists, etc. This will help to ensure that practitioners have the support of a multidisciplinary team to draw on, including community-based referrals from antenatal care to postnatal care. This may also help to reduce the number of unnecessary appointments and can enhance communication and self-management.
	Offer mental health services with routine antenatal and postnatal care so that women have easy access to these essential services. Ensure that mental health services are available in person and virtually to overcome stigma and societal barriers (particularly in small regional towns).
	Combine maternal health services with routine child health care (vaccinations and routine check-ups) so that women can also access timely health care.
	Ensure flexible childcare options based in healthcare settings so that mothers can access timely healthcare. Consider system level support such as transport support required to remove barriers to access to health care.
	Partner with organisations (eg. TasCOSS) and community centres to use them as Telehealth hubs to enhance access to healthcare services mainly in regional and remote areas to mitigate challenges that women and their families experience with telehealth such as accessibility, data, and digital literacy.
	Develop community of practice for stakeholders working in maternal and child health space (health professionals, public health team, allied health professionals, community centres etc.) across Tasmania to facilitate knowledge exchange and enhance multisectoral collaboration. Alternatively, identify the existing ones and integrate them together.
	Use an inclusive and family centred approach to maternal and child health care to promote healthy lifestyle practices.
	Ensure flexible and supportive workplaces for mothers (maternity leave, paternity leave, workplaces and infrastructure that support breast feeding and promotes physical activity)
Harness family, social and community networks to support and empower women and their children. “It’s not always about the partners as well. It could be the broader context of the culture that women just I think mothers just need support however it looks. So, it could be friends, it could be their own parents. It could be their own siblings. It could be their partner whoever it is. It’s it takes a village to raise a child and it’s I think it’s really common for people to feel quite alone, doing it all themselves at you know, at this point in time, we just we live so, so much on our own, so independently that it’s hard when you have kids” (P1-W1) “I guess it depends. I mean, what she probably really needs is some sort of like a ‘health connector’. Someone that can help explain a little bit about the process. And I think one of the challenges that I’ve seen in our work in health literacy is that it’s hard to find the right person to go and talk to about that” (P6-W1) “To teach that the value of community connectors cannot ever be underestimated, and in fact, we don’t utilize them nearly well enough in Australia. But for people who don’t have good health literacy, the value of community connectors is critical” (P10-W1)	Using a family centred approach to work with pregnant women’s partner and family and explore community supports to optimise their health during and after pregnancy. This opportunity can also be used to educate and inform partners and families about women’s experiences during and after pregnancy and how sharing responsibilities in the household (e.g., house chores) can help to improve the health of the mother and their children. Normalise this behaviour to help overcome cultural and societal barriers (e.g., Dads4Kids program).
	Identify health connectors/mediators to assist women to navigate the healthcare system and access appropriate health services and information. Local trusted community members can be trained and used as health connectors to understand the needs of women and connect them with essential health services. In addition, medical students and future health professionals could be encouraged to fill this gap in their coursework and training.
	*Identify and link mothers to community or social groups (of their interest) to enhance social connections and active living and facilitate shared knowledge. These groups should be both in-person and virtual.
	Enhance the use and upscale successful existing programs such as ‘Pregnancy Buddy’ facilitated by local community champions and nurses to help pregnant women to build social connections, impart knowledge, access health services and engage in healthy lifestyle practices.
	Upskill community members to strengthen social capital so that everyone feels encouraged to support and look after each other.
Address societal and cultural norms around pregnancy and motherhood. “I think reminding people that sometimes you’ve got to ask a few people a few times, and just reinforcing that message of it’s okay to ask and if you don’t get the right answer, don’t stop. And I guess that encouraging message that sometimes is tricky and it shouldn’t be so tricky and there should be all the strategies to try and make it less tricky to navigate. But I think even with all those in the world, it’s still going to be complex. So, it’s getting that message out there too” (P15-W1)	Develop resources to demonstrate real life experiences (ups and downs) of pregnant women and mothers. Employ storytelling that includes community storytellers to demonstrate their real-life stories and set realistic expectations around motherhood. Storytelling could be integrated with the existing B4 Community Storytellers Program.
	Normalise and reinforce that the pregnancy and motherhood journey can be different for different women and that it is normal to ask for support if mothers are confused or not confident.
	Address importance of culture in influencing health literacy, health behaviours, self-efficacy and health outcomes of pregnant women and mothers and design solutions accordingly.
	Engage community leaders or trusted community members to positively influence traditional, societal and cultural norms about pregnancy and motherhood.

* Group sessions and face to face mother groups have not been consistently delivered in many regions in Australia because of COVID.

1. Provide access to locally relevant and context-specific evidence-based health information.

   This strategy includes solutions to provide locally relevant health information so women can apply that information in Tasmanian context to effectively inform their health decision making.

“It’d be great, wouldn’t it, if there was a spot that you could go to and say, “yes, this is aged care, dental needs, mental health, this is where you go, and you know you’re going to get the correct answers “(P13-W1)

1. Provide effective resources and adapt communication to respond to diversity and meet the needs of all women.

   This strategy includes solutions for providing inclusive and clear communication to ensure information shared with the target user is easy to understand and apply to inform health-decision making.

"Something that we’ve noted here, but also resources that are available are either too wordy, but we’re working now to look at more engaging visual resources help you know, in acknowledgment that there’s not good information for women.” (P11-W1)

1. Build the capacity of the health system and health providers to respond to the diverse needs and preferences of women.

   This strategy includes solutions which suggest that healthcare providers and health systems need to be regularly upskilled, so they are responsive to the health and broader needs of women from different socioeconomic and cultural backgrounds.

“I think just maybe supporting the GP’s as well around how they can support people just in their empathy for people, their listening skills, maybe using some motivational interviewing techniques so that people don’t walk away feeling judged” (P1-W1)

1. Provide a tailored, integrated and multidisciplinary approach to maternal and child healthcare.

   This strategy includes solutions to integrate maternal and child health services with specialist health services, so women have timely access to quality healthcare.

“You know, can the GP and the specialist work together more closely so that the GP could do some of the more like the testing and things that needs to happen as part of those gestational diabetes appointment services, then having the telehealth option to then meet with the specialist and they have that information” (P2-W1)

1. Harness family, social and community networks to support and empower women and their children.

   This strategy includes solutions which suggest using a family-centred and community-centred approach to enhance social support for women during pregnancy and beyond.

“I guess it depends. I mean, what she probably really needs is some sort of like a ‘health connector’. Someone that can help explain a little bit about the process” (P6-W1)

1. Address societal and cultural norms around pregnancy and motherhood.

   This strategy includes solutions which suggest using culturally sensitive approaches to improve the health of pregnant women, mothers and their children.

“I guess it’s about the conversations that could be happening at the community level in terms of, you know, not having to be seen as this, you know what perfect mother is, and if you don’t get the dishes done today, not the end of the world, we all have days like this, we’ll have weeks like these” (P1-W1)

Consistent with the Ophelia process, codesigned solutions were further categorised at a policy, practitioner, family, community and/or individual level. As shown in Table 2, the codesigned solutions targeted all levels. Solutions were most commonly targeted at both the policy and practitioner levels (n = 10), followed by the policy level (n = 9), practitioner level (n = 3) and the community/family level (n = 3) (see Table 2).

Recommendations for implementation of solutions

During Phase 5 workshops, four recommendations (with 20 supporting ideas) were generated to guide the implementation of the codesigned solutions in the Tasmanian context (see Table 3 for recommendations and supporting quotes). The recommendations included:

Table 3. Recommendations (Phase 5) made by stakeholders to support implementation of co-designed solutions.

Recommendations for implementation	Supporting ideas
Establish multisectoral collaboration and partnerships with existing organisations and community services and stakeholder engagement to map existing programs/services and build on them or upskill them instead of starting new programs. “And I think using the existing structures, rather than creating a whole new structure. The existing structures and networks that are out there and sharing these ideas and thoughts and who it might be that one group takes on one suggestion and another group takes on another suggestion” (P5-W2) “You know although you know some of what’s already there, it’s really important I think to get down to what exactly is out there, because there’s no point developing and implementing solutions to things that there may already be solutions for somewhere else. So, getting those stakeholders together to map the value stream to see where the pain points are to see where the positive points are and to work these solutions into that. I think would be most beneficial” (P7-W2) “So the child and family learning centres, for example, the few that I’ve engaged with so far, and one of them, I was fortunate enough to visit as a part of a research project. And they have such trust in the community and then they’re almost seen as family or extended family, so I guess tapping into where people have already got those strong connections and then working with the staff within those centres to sort of upscale them and get the messages out through that way I guess is probably you know one way that it could be looked at, so yeah I guess again working with existing things in place and they have really that trust in those centres” (P4-W2)	Partnership with existing programs or organisations working in maternal and child health space such as Child and Family Learning Centres, Launch into Learning Programs, Playgroup Tas etc and upskill them to deliver family inclusive healthy lifestyle programs, reinvigorate and sustain mother groups and implement pregnancy buddy programs.
	Partner with Health Consumers Tas, 26TEN, B4 Early Years Coalition, and Child and Family Learning Centres to develop health information hubs for pregnant women, partners and families. This partnership can help to train existing and new health connectors and mediators in the community to deliver a community storytellers program (for example B4 storytellers’ program).
	Integrate a specific maternal health helpline within existing health helpline like Health direct instead of creating a new one. This can be a useful referral point for already burdened antenatal and community practitioners. For example: Something similar to Federal Government Pregnancy Birth and Baby program but adapting to Tasmanian context.
	Integrate primary and specialist health services with community services like child and family learning centres and neighbourhood houses to enhance access and reduce number of appointments and wait lists. Ensure mental health services are included. For example, newly established Kids Care Clinics (Community-based paediatric services)
	Partner or collaborate with Department for Education, Children and Young People or real estate companies/or agents to deliver welcome information packs (consisting of information about health and community services in the community) for new families moving into the area.
	Start an online community of practice to enhance multisectoral collaboration, facilitate stakeholders’ engagement and knowledge exchange in maternal and child health space. Use this as a mechanism to keep track of existing and new health services.
Enhance system level support through creating a responsive health system, providers and policy level changes. “We have a super supportive environment when it comes to returning to work and breastfeeding, and I still found it so incredibly hard and had my partner’s work be more flexible, I feel like that would have been easier, so I feel like that’s something to look at. I know the second point, talks about supporting partners and family, but I feel like workplaces could do a lot, there’s just not a lot of parental leave for dads and it’s just not equitable in that way” (P2-W2) “Whether we could get funding for a Pregnancy App that is evidence based and not about whether it’s government one or something’s similar so that it’s not you know, we can tailor the messages how we want to and make it health literate and you know “Tasmanianified” (P2-W2) “To ensure that whatever information that you can then impart can be translated into languages or information that’s accessible to as that’s as relevant as possible to the Tasmanian community as a whole and that we’re not cutting off any particular parts of the community, because we’re just not aware of what their needs are. I think that that just happens a lot sometimes because it’s not that people don’t actually factor it into their consideration so it’s just it’s you know it’s not a purposeful exclusion it’s by accident, because they lack awareness” (P1-W2)	Create flexible workplaces and sufficient parental leave for both parents (where there are two), to ensure partners are available to support new mothers.
	Establish and support neurodevelopmental services in primary health care space to support mothers and their children. Ensure services work in a trauma informed way.
	Establish or integrate (with Find Help Tas or Little Tasmania website) Government facilitated central health information repository (or dashboard) containing evidence-based information about all topics relevant to maternal and child health. Ensure repository contains information about health and community services available, along with alternative options, cost and wait times. Develop a user-friendly mobile App to facilitate access for pregnant women and mothers.
	Engage translators, bilingual educators or community champions in the development and dissemination of information in multiple languages and multiple formats so it is easy to understand for pregnant women, mothers, partners and families from different cultural backgrounds.
	Streamline and support the use of community newsletters to disseminate information about health and other services available in the community to support pregnant women and mothers. Ensure information is disseminated in multiple languages.
Enhance support and build the capacity of current and future health workforce. “I think getting it into the medical training fairly early on, so it’s just habit to refer to it and automatically assume and that asking someone if they know where to go for the next process is as natural as a nurse is taking them blood pressure, for example, it’s just ingrained and automatically happens automatically, without thinking about it” (P5-W2) “One of the best comments I heard from a healthcare professional when we were talking about something in training. They actually say to their patients, so if you’re going to go home and talk to your partner or your mom or whatever about what we’ve talked to that talked about today, what would you tell them and then it’s like that teach back umm but just worded differently, I thought it was a really great way of introducing that concept” (P5-W2)	Integrate capacity building efforts for health providers into existing orientation programs or with existing information pathways such as Tas health pathways.
	Provide one-on-one appointments followed by group sessions for gestational diabetes and where appropriate post-natal anxiety/depression to overcome access and wait time issues.
	Train health professionals (through undergraduate training and professional development) to implement health literacy principles for example teach-back technique in day-to-day practice.
	Ensure communication, listening and empathy is adequately taught as a part of curriculum for health professionals. Provide students with practical experience of working in different communities and cultural settings.
	Consider that health care providers are overwhelmed (which has been accelerated due to COVID) so it is important to ensure that we are not adding more pressure to a currently overburdened health system.
Empower women and our future generations to ask questions, share experiences and advocate for their health. “I think there needs to be a focus on how to improve I mean every encounter that a mum has on her journey. You know whether it’s antenatal or postnatal or then in those early years with their child every encounter, whether it be with their health professional or with the social service or in their community is an opportunity to kind of improve health literacy “(P1-W2) “We just need people to stand up and talk early and say this was my experience. Because the more people that talk about their experiences. Like my depression I’m pretty open about that, but the more people that talk about it, the more people understand that it’s not the worst thing in the world that can happen And you know, because you can say you know 30% of people develop postnatal depression, but it’s like I don’t know any of that 30% so how can I be part of that you don’t identify with it. But in regard to the questions about normalizing and reinforcing that it’s normal to ask questions” (P5-W2)	Create enabling environments by increasing awareness and addressing the social determinants of health and existing inequities to reduce intergenerational disadvantages. Empower women and future generation to advocate for their health and implement the information in local context.
	Encourage mothers, partners and families to share their real-life experiences, through storytelling and their local networks. To overcome stigma and societal barriers, stories should be balanced and include experiences with weight gain, gestational diabetes, post-natal depression and other conditions associated with motherhood.
	Create awareness or educate pregnant women and mothers about existing services and programs to support and engage them in healthy lifestyle practices.
	Ensure that every woman’s encounter with the health system is an opportunity to address their health and other needs and to support and empower them during pregnancy and beyond to improve their health and the health of future generations.

1. Establish multisectoral collaboration and partnerships with existing organisations and community services and stakeholder engagement to map existing programs/services and build on them or upskill them instead of starting new programs.

"We really need the government to recognize how important it is to embed health within the community, because that improves access ………. One example is the child and family Centre at Bridgewater which is now staffed with a paediatrician umm in two sessions per week, ….There are opportunities for other allied health professionals to also be involved” (P1-W2)

1. Enhance system-level support through creating a responsive health system, providers and policy-level changes.

“We have a super supportive environment when it comes to returning to work and breastfeeding, and I still found it so incredibly hard and had my partner’s work be more flexible, I feel like that would have been easier” (P2-W2)

1. Enhance support and build the capacity of current and future health workforce.

“The social media training for example for healthcare professionals is that something that needs to be built into almost like that orientation. You know when we first become part of the department there’s certain things that you meant to like to complete the online training and things like that. So are there ways that they can be built into their systems” (P4-W2)

1. Empower women and our future generations to ask questions, share experiences and advocate for their health.

“I think there needs to be a focus on how to improve every encounter that a mum has on her journey., whether it’s antenatal or postnatal or then in those early years with their child. Every encounter, whether it be with their health professional or with the social service or in their community is an opportunity to kind of improve health literacy “(P1-W2)

As shown in Figure 4, the first three recommendations can collectively support the fourth recommendation - to empower women and our future generations to advocate for their health.

Figure 4. Recommendations (Phase 5) to support the implementation of codesigned solutions.

Discussion

This study aimed to codesign health literacy solutions for pregnant women and mothers in Tasmania and to develop a set of locally informed recommendations to guide the implementation of identified solutions. The codesign workshops generated multiple solutions and recommendations grounded in the local knowledge and expertise of the various stakeholders. This study demonstrates how the careful consideration of the health literacy needs of pregnant women and mothers, and effective engagement of all relevant stakeholders in planning and designing public health solutions can support the development of new fit-for-purpose context-specific solutions and ideas for tailoring existing solutions. The codesigned solutions bring us a step closer to developing a health literacy-responsive environment in Tasmania. This may play a crucial role in improving health outcomes for pregnant women, mothers and their children and provide adequate support to reduce the intergenerational impact of NCDs in Tasmania.

Most of the identified solutions were targeted at the policy, practitioner, and family/community levels. The solutions were rarely focused on the individual level, suggesting our stakeholders recognised the importance of taking a holistic approach to addressing the health literacy needs of pregnant women and mothers instead of placing the entire burden on the individuals. The solutions were not limited to the health sector. Instead, solutions highlighted the need to address broader social determinants of health to create an enabling and health literacy-responsive environment in Tasmania. Incorporating broader social determinants of health in health and other policies can play a crucial role in influencing health behaviours, improving health outcomes and reducing health inequities (Baum & Fisher, 2014). This can be achieved by using innovative policy strategies like a “Health in All Policies (HiAP)” framework (Kickbusch, 2009). The HiAP framework encourages the incorporation of health as a core component in policy development across different agencies and sectors and to collectively address key determinants of health to promote health and improve health outcomes (Kickbusch, 2009). These findings encourage policymakers to focus on broader social determinants of health while developing solutions and interventions to improve the health of women and their children.

The codesigned solutions highlighted that evidence-based, locally relevant and tailored information (in-person and digital) should be provided through a government-facilitated central information portal (website and mobile application). Previous research has shown that pregnant women and mothers often trust health information sources endorsed by the government or their healthcare providers (Caddy et al., 2023; Hearn et al., 2013). Therefore, a government or healthcare provider-endorsed central information portal or local health information hubs tailored specifically for pregnancy and motherhood could enhance women’s access to credible health information and help to maintain the consistency of health information shared across Tasmania. Further, our research findings suggest adapting the information in multiple formats and languages to address the needs of pregnant women and mothers from diverse socio-economic and cultural backgrounds. The findings echo other studies which highlight the importance of understanding the health information needs of women to develop clear, consistent, tailored, engaging and informative resources to support women to make informed decisions to improve their health and their children’s health (Caddy et al., 2023; Gourounti et al., 2022; Kamali et al., 2018).

This research highlights that capacity building of current and future health professionals is required to enhance their communication, listening and digital skills to become more responsive to the health and broader needs of pregnant women and mothers in Tasmania, particularly for those from diverse educational and socio-economic backgrounds. The use of clear communication free of medical jargon and empathy are considered to be important determinants of consumers’ trust in healthcare providers (Chandra et al., 2018). Further, trust in healthcare providers is associated with increased patient satisfaction and improved health behaviours and health outcomes (Birkhäuer et al., 2017). Capacity building of healthcare providers could enhance the trust of pregnant women and mothers accessing the Tasmanian health system and positively influence their health outcomes. The Australian Commission on Safety and Quality in Health Care (Australian Commission on Safety and Quality in Health Care, 2014) recommends that healthcare providers should use the “teach-back” method as a universal communication approach to ensure that the information shared by them is understood by the consumer. The use of the teach-back method has been found effective in improving communication outcomes, knowledge and self-care abilities of consumers in different health settings (Talevski et al., 2020). Reinforcing and incorporating the use of simple communication methods such as teach-back in healthcare settings can help to enhance pregnant women and mothers understanding of the shared health information.

Further, with the increasing use of digital technology in managing health, it is essential to upskill the digital capacity and skills of health systems and healthcare providers to effectively optimise digital technology to address the health and broader needs of women during and after pregnancy (Caddy et al., 2023). Policymakers and education institutions should ensure the inclusion of the digital and telehealth education and training for current and future healthcare providers to effectively utilise digital technology to improve the health of women and future generations.

This research calls for tailored, integrated and multidisciplinary approaches to maternal and child health. This is to ensure that pregnant women and mothers have timely access to essential health services. The use of an integrated and tailored approach to antenatal and postnatal care can increase the uptake of essential health services and improve health outcomes for women and their children (De Jongh et al., 2016). Widening the scope of maternal health services by integrating them with existing NCDs screening and preventive services could help to reduce the future NCDs burden (Firoz et al., 2018). Integrating maternal health with routine newborn and child health services can help to capitalise the presence of women at a healthcare facility, enhance their engagement with postnatal health services and maintain their continuity of care (Connor et al., 2018; World Health Organisation, 2015). These findings collectively suggest that using a multidisciplinary approach to maternal and child healthcare may help to ensure that all women attain the highest achievable level of health during pregnancy and beyond.

This research highlights the need to address broader social, societal and cultural factors to improve the health of women and their children in Tasmania. Societal and cultural factors and norms can influence health decision-making and access to healthcare for pregnant women and mothers and may influence their health outcomes (Lindsay et al., 2016; Omer et al., 2021). This is closely linked to the concept of ‘distributed health literacy’ which highlights the intersection between health literacy and the social and cultural context (Muscat et al., 2022). Distributed health literacy acknowledges that health literacy is distributed across families, social connections and communities and can influence the acquisition of health information and health decision-making of individuals and communities, and consequently access and use of healthcare (Edwards et al., 2015). The use of peer mother groups (Cameron et al., 2019), peer support programs (McLeish & Redshaw, 2019), community connectors (Wallace et al., 2020) and community storytelling programs (Greenhalgh, 2016; Limaye et al., 2018) can help to optimise distributed health literacy and address the social and cultural factors by enabling pregnant women and mothers to share knowledge and real-life experiences of managing their health and health of their children. Harnessing family, social and community networks can help in creating a collective mothering village (Neely & Reed, 2023) which can promote maternal emotional wellbeing and self-efficacy and reinforce the development of social connections, social capital and community resilience necessary to support pregnant women and mothers to improve their health and their children’s health (Cameron et al., 2019; Wind & Villalonga-Olives, 2019). It should be noted that peer mother groups and other social support programs have been negatively impacted by the COVID-19 pandemic. The short-term impacts have been reported (Lubbe et al., 2022; Turner et al., 2022) but the long-term impacts of this disconnection are yet to be fully realised. This finding highlights a need to reinstate mother support groups in Tasmania and globally so that mothers can access necessary support to look after themselves and their children.

This research generated recommendations to support the implementation of identified solutions for pregnant women and mothers living in Tasmania. One of the important recommendations was to enhance multisectoral collaboration and establish partnerships with existing organisations, community services and stakeholders to map existing programs and services. The stakeholders recommended that efforts should be taken to build on existing programs or upskill them instead of starting new programs. Multisectoral collaboration is essential to ensure that all the sectors and services work together towards a shared goal to create an enabling and supportive environment to promote and improve the health of women and future generations and address health inequalities (Babajide et al., 2022; Hinton et al., 2021). Policymakers and health systems must act now to take meaningful actions to enhance the collaboration and engagement of local stakeholders and organisations to map the existing health, community and social services and tailor those services to respond to the health and broader needs of pregnant women and mothers in Tasmania. In doing so they can effectively support women to engage in healthy lifestyle practices and improve health outcomes for themselves and their children.

Strengths and limitations

This research is the first in Australia to use a codesign process like Ophelia to engage relevant stakeholders to codesign solutions to address the health literacy and broader needs of pregnant women and mothers. The use of a codesign approach ensured that the perspectives of both the users and providers were taken into consideration during planning and designing of the health literacy solutions. The codesign of context-specific solutions grounded in local knowledge and expertise can support the development of a health literacy-responsive environment more likely to respond to the health and broader needs of pregnant women and mothers in Tasmania.

As the solutions and recommendations generated were based on the personal knowledge and experiences of the participating stakeholders, the evidence of the effectiveness and feasibility of codesigned solutions to improve health and equity outcomes for pregnant women and mothers still needs to be established. This study warrants the need for future research (implementation and evaluation) to determine if the codesigned solutions are responsive to health and broader needs and improve health and equity outcomes for pregnant women and mothers in Tasmania. Even though online delivery (via Zoom) of workshops facilitated the engagement of diverse stakeholders across Tasmania, the participation of some valuable stakeholders who might have had limited access to the internet and digital technology or limited digital literacy may have been constrained by the exclusive use of the online platforms. Future research may consider a hybrid model (in-person and/or online) based on the preferences of the stakeholders to enhance their participation and engagement in designing public health solutions. Further, the codesigned solutions and recommendations were not related to any specific health setting or health condition(s) and cover a broader scope of health for this population group. Therefore, the codesigned solutions may not be responsive to managing a specific health condition (e.g., diabetes or mental health conditions). Instead, these solutions can be used as a starting point for improving health literacy responsiveness of specific health services to prevent or manage a particular health condition in this population group.

Conclusion

This study demonstrated that the collaborative engagement of relevant stakeholders can support the codesign of diverse solutions and implementation ideas grounded in local wisdom and expertise that may improve the health and equity outcomes for pregnant women and mothers in Tasmania. The codesigned solutions reinforce the need for using holistic and multi-level approaches to address health literacy and broader needs of pregnant women and mothers, rather than placing the entire burden on individuals. The solutions suggest enhancing multisectoral collaboration and integration of maternal and child health services with broader health (specialist and allied healthcare) and social and community services to ensure women and their children have timely access to quality healthcare. Most importantly, the solutions focused on addressing the broader social determinants and cultural and community factors influencing the health and well-being of pregnant women and mothers in Tasmania. The codesigned solutions are a gentle reminder for policymakers and health organisations to consider tailored strategies that move away from “one size fits all” approaches. Future efforts must engage the target population and relevant stakeholders in the planning and design of locally relevant fit-for-purpose solutions which can be tailored to respond to the local needs, culture and context. Other regions nationally and globally may consider adopting this codesign approach to support efforts to reduce the future burden of NCDs. This can help to ensure that all women are supported to engage in healthy lifestyle practices and have adequate and timely access to quality healthcare to attain the highest achievable level of health and wellbeing for themselves and future generations.

Acknowledgment

The authors thank Gina Melis for her assistance in some of the codesign workshops.

Disclosure statement

The authors report there are no competing interests to declare.

Data availability statement

The data that support the findings of this study are available on reasonable request from the corresponding author. The data are not publicly available due to ethical concerns and privacy of research participants.