Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis

Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review

BACKGROUND

Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs.

METHODS

We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author.

RESULTS

We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change.

CONCLUSIONS

Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Exploring a framework for demandable services from antenatal to postnatal care: a deep-dive dialogue with mothers, health workers and psychologists

BACKGROUND

One of the factors affecting quality of care is that clients do not demand care practises during antenatal, intrapartum and postnatal care. This study aimed to identify care practices that can be demanded by the mother in the continuum of care from antenatal to postnatal.

METHODS

The study respondents included 122 mothers, 31 health workers and 4 psychologists. The researchers conducted 9 Key Informant Interviews with service providers and psychologists, 8 Focus Group Discussions with 8 mothers per group, and 26 vignettes with mothers and service providers. Data was analysed using Interpretative Phenomenological Analysis (IPA) where themes were identified and categorised.

RESULTS

During antenatal and postnatal care, mothers demanded all recommended services presented to them. Some services seen as demandable during labour and delivery included 4-hourly assessments of vital signs and blood pressure, emptying of the bladder, swabbing, delivery counselling, administration of oxytocin, post-delivery palpation, and vaginal examination. For the child mothers demanded head to toe assessment, assessment of vital signs, weighing, cord stamp and eye antiseptics, and vaccines. Women observed that they could demand birth registration even though it was not among the recommended services. Respondents proposed empowerment of mothers with cognitive, behavioural and interpersonal skills to demand services e.g., knowledge of service standards and health benefits in addition to improved self-confidence and assertiveness. In addition, efforts have to be made to address perceived or real health worker attitudes, mental health for the client and the service provider, service provider workload, and availability of supplies.

CONCLUSION

The study found that if a mother is informed in simple language about services that she is supposed to receive, she can demand numerous services in the continuum of care from antenatal to postnatal. However, demand cannot be a standalone solution for improving quality of care. What the mother can ask for is a step in the guidelines, but she cannot probe deeper to influence quality of the procedure. In addition, empowerment of mothers needs to be coupled with services and systems strengthening in support of health workers.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Demand–supply-side barriers affecting maternal health service utilization among rural women of West Shoa Zone, Oromia, Ethiopia: A qualitative study

Introduction

Despite the efforts and strategies being applied by the government and the partner organizations to increase maternal health service utilization, maternal health service utilization is low in the general population and very low in rural communities of the West Shoa Zone specifically.

Objective

This study intended to identify and describe barriers contributing to low maternal health service utilization in selected rural districts of the West Shoa Zone of Oromia regional state, Ethiopia, by 2021.

Methods

The study was conducted from February 01 to April 30/2021 in three districts of the West Shoa Zone. The districts were selected purposively based on the report of their last year’s (2020) performance on maternal health service utilization obtained from the Zonal health office, where the ANC follow-up and Institutional delivery were the lowest among the Districts in the Zone. A community-based qualitative phenomenological approach was used to explore the demand-supply side barriers affecting the utilization of maternal health services. Six Focus Group discussions, 9 In-depth Interviews, and 12 Key Informants Interviews were conducted with women who gave birth at home in the last 12 months and with health care providers at different health offices and health institutions. Data were tape-recorded, transcribed verbatim, translated, and analyzed thematically using MAXQDA software.

Results

Our findings revealed that though women strongly agree on the importance and advantage of maternal health services utilization, both demand and supply side barriers such as low awareness on when to use the services, not knowing ANC schedule, misinformation about ANC and institutional delivery, not knowing their estimated date of delivery and precipitated labor, shortage of manpower at health institutions, far distance health facilities, and unavailability or un-accessibility of ambulance services during an emergency time, lack of transportation to health facilities were hindering them not to use the services.

Conclusion

In general, rural women are facing many challenges yet to accessing and utilizing maternal health services. To achieve the SDG targets, addressing barriers prohibiting a woman from using MCH should be critically addressed.

Quality of intrapartum care at Public Health Institutions of North Achefer District, North West Ethiopia: a mixed method study

Background

Ending preventable maternal, and neonatal morbidity and mortality cannot be achieved without quality care interventions during the intrapartum and postpartum period. Poor quality care during the intrapartum and postpartum period contributes high burden of maternal and neonatal morbidity. Therefore, the current study aimed to assess the quality of intrapartum care and its associated factors in public health facilities in North Achefer District, North West Ethiopia.

Method

A mixed-type institution-based cross-sectional study design was conducted from November 7 to December 6, 2019. Simple random sampling and purposive sampling were used to select study participants for quantitative and qualitative studies respectively. Data were coded and entered into Epi data version 4.4.2 software and exported to SPSS version 25 for analysis. Variables with a p-value of less than and equal to 0.25 were entered into multivariable regression analysis and variables with p values < 0.05 were considered statistically significant factors of the quality of intrapartum care. The qualitative data were analyzed by using thematic content analysis. Finally, qualitative findings were used to supplement the quantitative result.

Result

The finding showed that, 27.3% (95% CI: 26.6–28) of mothers received good quality intrapartum care. Presence of long-distance (AOR = 0.19; 95% CI = 0.06, 0.66), health care facility (AOR = 0.07; 95% CI = 0.02, 0.20), and partograph utilization (AOR = 4.9; 95% CI = 1.82, 13.14) were factors associated with the quality of intrapartum care.

Conclusion

The proportion of intrapartum quality care was low. Distance, partograph utilization, and type of health facility were factors associated with quality of intrapartum care. The district, zonal health offices, and regional health bureau should provide capacity building and follow up on partograph utilization, and increase the accessibility of ambulances.

Gap Analysis: Quality and Women's Satisfaction Regarding Postnatal Care

Background:

Improving the quality of maternal health is one of the eight major developmental goals of the World Health Organization. Women's satisfaction with maternity healthcare services is a crucial indicator of quality health care.

Objective:

This study aimed to evaluate the gap between the quality of maternity care and women's satisfaction with postnatal care.

Methods:

This study used a descriptive cross-sectional study design. The sample size was 300 postpartum Saudi women. The data were collected from the postnatal care unit at the King Khalid Hospital, Jeddah, Saudi Arabia, The study used the SERVQUAL and Postnatal Satisfaction with Nursing Care Questionnaires to measure the studied variables.

Results:

The mean ± SD (3.73 ± 0.466) of women perceived that the provided care was of high quality and the mean ±SD (3.20±0.511) of women's satisfaction with postnatal care was moderate. The gap between expected and perceived quality of maternity care was reported to be -1.27. There is a significant positive relationship between the quality of maternity care and women's satisfaction.

Conclusion:

The study concluded that the participants were generally satisfied with the postnatal care and overall maternity care provided in the King Khalid Hospital. However, they showed the desire to get more empathetic care. Patients' satisfaction should be evaluated periodically to establish baseline data and provide postnatal care interventions tailored to women's expectations. There is a need to increase training for enhancing healthcare providers' empathetic and communication skills to improve the relationship between the staff and women.

Improvement in Quality of Life through Self-Management of Mild Symptoms during the COVID-19 Pandemic: A Prospective Cohort Study

The COVID-19 pandemic has inhibited people's help-seeking behaviors (HSBs). In particular, older people in rural communities experienced limited access to medical care, which negatively affected their quality of life (QOL). Within HSB, self-management of mild symptoms may mitigate the difficulties experienced by older people in rural communities. However, few studies have examined the relationship between self-management and QOL. Therefore, we conducted a prospective cohort study to clarify this relationship. Our participants were over 65 years of age and lived in rural communities. QOL was measured with the EuroQol 5-Dimension 5-Level (EQ-5D-5L). Demographic data and QOL were collected from participants via questionnaires in 2021 and 2022. The exposure group showed a significantly greater change in EQ-5D-5L health status index scores than the control group (p = 0.002). In addition, the exposure group scored significantly lower than the control group on the EQ-5D-5L dimension "usual activities" in 2021 and on all dimensions in 2022. Thus, self-management of mild symptoms may improve QOL among older people in rural communities during the COVID-19 pandemic. Educational interventions for this population regarding self-management could improve QOL for entire communities.

Potential Help-Seeking Behaviors Associated with Better Self-Rated Health among Rural Older Patients: A Cross-Sectional Study

Help-seeking behaviors (HSB) for mild symptoms vary because of differences in health care resources and patients' backgrounds. Potential HSBs for lay and professional care use are related to patients' health conditions. However, there is a lack of evidence of the relation between them. This study examined the relation between patients' potential HSBs and self-rated health (SRH). The cross-sectional study involved 169 patients, aged above 65 years, who visited a Japanese rural clinic. A validated checklist was used to assess potential patients' HSBs. A chi-square test and logistic regression were performed to examine the relation between patients' self-rated health and HSB regarding lay and professional care use. Participants were 77.5 years old, on average (SD = 8.3). Results reveal that having regular exercise habits (OR = 2.42, p = 0.04), adequate sleep (OR = 4.35, p = 0.006), work (OR = 2.59, p = 0.03), high socioeconomic status (OR = 6.67, p = 0.001), and using both lay and professional care (OR = 2.39, p = 0.046) were significantly correlated with high self-rated health. Living alone was negatively correlated with higher SRH (OR = 0.23, p = 0.015). To improve rural patients' health care, in addition to improving their health management skills, potential HSB for mild symptoms should be investigated and interventions that consider patients' socioeconomic factors and living conditions should be implemented.

The Association between the Self-Management of Mild Symptoms and Quality of Life of Elderly Populations in Rural Communities: A Cross-Sectional Study

Maintaining people’s health based on their help-seeking behavior (HSB) regarding mild symptoms is essential. An effective HSB, especially self-management, can facilitate the attainment of appropriate healthcare resources and affect health outcomes such as quality of life (QOL). However, clear evidence regarding the relationship between self-management, mild symptoms, and QOL is unavailable. Therefore, this cross-sectional study investigated this association in a rural elderly population. The participants, aged over 65 years, were living in rural communities. The primary outcome of QOL was examined using the EuroQol 5-Dimension 5-Level (EQ-5D-5L). After adjusting for propensity score matching, 298 participants in the self-management usage group were matched with 298 in the group not using self-management. The most frequent HSB trend was consulting with primary care physicians, followed by self-care, consulting with families, utilizing home medicines, and buying medicines. The EQ-5D-5L scores were statistically higher in the self-management usage group than in the other group. The HSBs with a trend of using self-management were related to a high QOL. Self-management of symptoms along with other HSBs can improve elderly HSBs in rural contexts. Educational interventions and system development for HSBs in rural contexts could be effective in enhancing the QOL of rural elderly populations.

Interventions to improve infant and young child feeding practices in Ethiopia: a systematic review

OBJECTIVE

In Ethiopia, despite the implementation of several interventions to improve infant and young child feeding (IYCF) practices, no published studies have highlighted the most effective IYCF interventions in the country. This systematic review investigated the impacts of various interventions on IYCF in Ethiopia.

SOURCE OF INFORMATION

A systematic search was conducted on seven computerised bibliographic databases (Embase, ProQuest Central, Scopus, PsycINFO, Web of Science, MEDLINE/PubMed and CINAHL) to locate experimental or quasi-experimental studies published between the year 2000 and May 2021.

STUDY ELIGIBILITY CRITERIA

Interventional studies that measured IYCF indicators (early initiation of breast feeding (EIBF), exclusive breast feeding (EBF), the introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet) as outcome variables were included.

STUDY APPRAISAL AND SYNTHESIS

All included studies were examined for biases related to interventional studies (ie, selection bias, performance bias, attrition bias, detection bias and reporting bias). Author reports of effect size measures were used to narratively report the findings of each study.

RESULTS

Of the 23 eligible studies, 14 studies were quasi-experimental and 9 studies were cluster randomised trials (CRTs). Eight quasi-experimental studies had a serious risk of bias, while two CRTs had a high risk of bias. Four studies for EBF and six studies for EIBF showed significant impacts of policy advocacy, health service strengthening, interpersonal communication, community mobilisation and mass media campaigns. Six studies for MDD and three studies for MMF indicated significant effects of community-level and health facility complementary feeding promotions on infants and young children. Interventions that delivered in combination increased the impacts in improving EIBF, MDD and MMF compared with a single intervention.

CONCLUSION

Our review showed that 12 out of 21 eligible studies that implemented in the form of community-level and health facility interventions improved EIBF, EBF, and/or MDD in Ethiopia.

PROTOCOL REGISTRATION NUMBER

PROSPERO, CRD42020155519.

What resources do elderly people choose for managing their symptoms? Clarification of rural older people's choices of help-seeking behaviors in Japan

Background

Appropriate help-seeking behavior (HSB) that involves lay and professional care may moderate the usage of medical resources and promote good health, especially among the rural elderly. However, there is little evidence regarding the rural elderly’s HSB choices for mild symptoms. Therefore, this study attempts to bridge this gap.

Methods

The participants were patients living in rural areas and over the age of 65, who attended Japanese clinics and general hospitals. In Phase 1, monthly diaries and one-on-one interviews about their mild symptoms and HSB were used to establish HSB items and assess its content validity. Content analysis helped determine the items. In Phase 2, participants were asked to complete the list to measure HSB. The answers to the list and HSB mentioned in the diaries were compared to evaluate concurrent validity. Retests were conducted to examine the content’s reliability and test-retest reliability.

Results

Phase 1 included 267 participants (average age = 75.1 years, standard deviation [SD] = 4.3; 50.1% male). The diary collection rate was 97.6%. Of the participants, 70.4% used lay care and 25.4% used professional care. Content analysis identified eight types of lay care and four types of professional care. Phase 2 included 315 participants (average age = 77.7 years, SD = 8.27; 46.0% male). In terms of validity, the results of the list and the diaries were correlated (Spearman r 0.704; p < 0.001). The most common behavior with mild symptoms was consulting with primary care physicians, followed by self-care and using home medicine. The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care.

Conclusions

The choices of HSB for mild symptoms clarified identified in this study have high validity and reliability. Therefore, it can be used to assess the relationships between HSB and health conditions and the effectiveness of health promotion on rural older people’s HSB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06684-x.

[Improving provision of mother-and-child care in Chad at the community level: A quasi-experimental study]

BACKGROUND

Chad is among the countries with the highest maternal and infant mortality rates in the world. An initiative aimed at improving mother-and-child health services was implemented from 2016 to 2019 in three rural health districts in southern Chad, with strong community input, while concomitantly increasing the supply and demand for care. The objective of this study is to evaluate the effects of this program on health service use.

METHODS

Interrupted time-series analyses with a control group was used to measure the effects of the intervention by applying a quasi-experimental approach. Monthly attendance data were collected from the registries of the 18 health centres that participated in the program and 18 centres that did not participate (control group), before (18 months) and after (24 months) the start of implementation.

RESULTS

On average, there were 10.98 (95% CI: 6.57-15.39, P<0.001) additional paediatric visits and 0.68 additional deliveries (95% CI: 0.42-0.95, P<0.001) each month in the participation group compared to the control group. Community involvement decisively contributed to the change.

CONCLUSION

During the 24 months of implementation, the initiative significantly increased the use of essential mother-and-child health services in Chad. This study highlights the benefits of a strong partnership with communities trained and involved in health system activities, with the objective of achieving universal health coverage.

Is patient navigation a solution to the problem of "leaving no one behind"? A scoping review of evidence from low-income countries

Patient navigation interventions, which are designed to enable patients excluded from health systems to overcome the barriers they face in accessing care, have multiplied in high-income countries since the 1990s. However, in low-income countries (LICs), indigents are generally excluded from health policies despite the international paradigm of universal health coverage (UHC). Fee exemption interventions have demonstrated their limits and it is now necessary to act on other dimensions of access to healthcare. However, there is a lack of knowledge about the interventions implemented in LICs to support the indigents throughout their care pathway. The aim of this paper is to synthesize what is known about patient navigation interventions to facilitate access to modern health systems for vulnerable populations in LICs. We therefore conducted a scoping review to identify all patient navigation interventions in LICs. We found 60 articles employing a total of 48 interventions. Most of these interventions targeted traditional beneficiaries such as people living with HIV, pregnant women and children. We utilized the framework developed by Levesque et al. (Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18) to analyse the interventions. All acted on the ability to perceive, 34 interventions on the ability to reach, 30 on the ability to engage, 8 on the ability to pay and 6 on the ability to seek. Evaluations of these interventions were encouraging, as they often appeared to lead to improved health indicators and service utilization rates and reduced attrition in care. However, no intervention specifically targeted indigents and very few evaluations differentiated the impact of the intervention on the poorest populations. It is therefore necessary to test navigation interventions to enable those who are worst off to overcome the barriers they face. It is a major ethical issue that health policies leave no one behind and that UHC does not benefit everyone except the poorest.

Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation

Introduction

We implemented a participatory quality improvement strategy in eight primary health care units of Ethiopia to improve use and quality of maternal and newborn health services.

Methods

We evaluated the effects of this strategy using mixed-methods research. We used before-and-after (March 2016 and November 2017) cross-sectional surveys of women who had children 0–11 months to compare changes in maternal and newborn health care indicators in the 39 communities that received the intervention and the 148 communities that did not. We used propensity scores to match the intervention with the comparison communities at baseline and difference-in-difference analyses to estimate intervention effects. The qualitative method included 51 in-depth interviews of community volunteers, health extension workers, health center directors and staff, and project specialists.

Results

The difference-in-difference analyses indicated that 7.9 percentage points (95% confidence interval [CI]: 1.8–13.9%) increase in receiving skilled delivery care between baseline and follow-up surveys in the intervention area that is attributable to the strategy. The intervention effect on postnatal care in 48 hours of the mother was 15.3% (95% CI: 7.4–23.2). However, there was no evidence that the strategy affected the seven other maternal and newborn health care indicators considered. Interview participants said that the participatory design and implementation strategy helped them to realize gaps, identify real problems, and design appropriate solutions, and created a sense of ownership and shared responsibility for implementing interventions.

Conclusions

Community participation in planning and monitoring maternal and newborn health service delivery improves use of some high-impact maternal and newborn health services. The study supports the notion that participatory community strategies should be considered to foster community-responsive health systems.

Effects of a community-based data for decision-making intervention on maternal and newborn health care practices in Ethiopia: a dose-response study

BACKGROUND

Community participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women's Development Army (WDA), was added to extend Ethiopia's Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA's Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy.

METHODS

Using data from cross-sectional surveys in 2010-11 and 2014-15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys.

RESULTS

Kebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth.

CONCLUSIONS

This study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.

Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis

BACKGROUND

Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices.

METHODS

We used cross-sectional data from a representative sample of 4684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding.

RESULTS

About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05).

CONCLUSION

We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates.

Correlates of the Women's Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia

BACKGROUND

To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women's Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices.

METHODS

Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents' individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest.

RESULTS

Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category).

CONCLUSION

Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.