1
|
Iroz CB, Ramaswamy R, Bhutta ZA, Barach P. Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review. BMC Health Serv Res 2024; 24:332. [PMID: 38481226 PMCID: PMC10935959 DOI: 10.1186/s12913-024-10802-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Cassandra B Iroz
- Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
| | - Rohit Ramaswamy
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Institute for Global Health & Development, The Aga Khan University, South Central Asia, East Africa, UK
| | - Paul Barach
- Thomas Jefferson University, Philadelphia, PA, USA
- Imperial College, London, UK
| |
Collapse
|
2
|
Dinis A, Fernandes Q, Wagenaar BH, Gimbel S, Weiner BJ, John-Stewart G, Birru E, Gloyd S, Etzioni R, Uetela D, Ramiro I, Gremu A, Augusto O, Tembe S, Mário JL, Chinai JE, Covele AF, Sáide CM, Manaca N, Sherr K. Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework. BMC Health Serv Res 2024; 24:164. [PMID: 38308300 PMCID: PMC10835896 DOI: 10.1186/s12913-024-10638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.
Collapse
Affiliation(s)
- Aneth Dinis
- National Department of Public Health, Ministry of Health, Maputo City, Mozambique.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Quinhas Fernandes
- National Department of Public Health, Ministry of Health, Maputo City, Mozambique
| | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Child, Family & Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ermyas Birru
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Stephen Gloyd
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ruth Etzioni
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | | | | | - Artur Gremu
- Comité para Saúde de Moçambique, Maputo, Mozambique
| | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, WA, USA
- Eduardo Mondlane University, Maputo, Mozambique
| | - Stélio Tembe
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Nélia Manaca
- Comité para Saúde de Moçambique, Maputo, Mozambique
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA, USA
| |
Collapse
|
3
|
Dadi TL, Abebo TA, Yeshitla A, Abera Y, Tadesse D, Tsegaye S, Gerbaba MJ, Worke MD, Tadesse D, Medhin G. Impact of quality improvement interventions on facility readiness, quality and uptake of maternal and child health services in developing regions of Ethiopia: a secondary analysis of programme data. BMJ Open Qual 2023; 12:e002140. [PMID: 37923343 PMCID: PMC10626795 DOI: 10.1136/bmjoq-2022-002140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/14/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Quality improvement intervention (QI) was implemented from 2018 to 2021 in health facilities of developing regional states of Ethiopia. The main objective of this study was to examine the impact of QI interventions on facility readiness, service availability, quality and usage of health services in these regions. METHODS We used district health information system data of 56 health facilities (HFs). We also used baseline and endline QI monitoring data from 28 HFs. Data were summarised using descriptive statistics and various tests. Regression analysis was employed to examine the impact of QI interventions on various outcomes. RESULT The QI intervention improved readiness of HFs, service availability and quality of maternal and child health service delivery. The mean availability of basic amenities increased from 1.89 to 2.89; HF cleanliness score increased from 4.43 to 5.96; family planning method availability increased from 4 to 5.75; score for emergency drugs at labour ward increased from 5.32 to 7.00; and the mean score for basic emergency obstetric and newborn care service availability increased from 5.68 to 6.75; intrauterine contraceptive devices removal service increased from 39.3% to 82.1%; and partograph use increased from 53.6% to 92.9%. HFs that use partograph for labour management increased by 39.3%. The QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7% and correct active third-stage labour management, a 19.6% improvement from the baseline. The interventions also increased the service uptake of maternal health services, but not significantly associated with improvement in contraceptive service uptake. CONCLUSION The integrated QI interventions in HFs could have an impact on facility readiness for service delivery, service accessibility and quality of service delivery. The effectiveness of the QI intervention should be evaluated using robust methods, and efforts to enhance contraceptive services through a QI approach requires further study.
Collapse
Affiliation(s)
- Tegene Legese Dadi
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- MERQ Consultancy PLC, Addis Ababa, Ethiopia
| | - Teshome Abuka Abebo
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Aklilu Yeshitla
- USAID Transform Health in Developing Regions, IntraHealth International, Addis Ababa, Ethiopia
| | - Yared Abera
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Derebe Tadesse
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Sentayehu Tsegaye
- USAID Transform Health in Developing Regions, Amref Health Africa, Addis Ababa, Ethiopia
| | - Mulusew Jebena Gerbaba
- Department of Epidemiology, Institute of Health Science, Jimma University, Jimma, Ethiopia
| | - Mulugeta Dile Worke
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Girmay Medhin
- MERQ Consultancy PLC, Addis Ababa, Ethiopia
- Aklilu Lema Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
4
|
Mukinda FK, Van Belle S, Schneider H. Local Dynamics of Collaboration for Maternal, Newborn and Child Health: A Social Network Analysis of Healthcare Providers and Their Managers in Gert Sibande District, South Africa. Int J Health Policy Manag 2022; 11:2135-2145. [PMID: 34523867 PMCID: PMC9808286 DOI: 10.34172/ijhpm.2021.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 08/11/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Accountability for maternal, newborn and child health (MNCH) is a collaborative endeavour and documenting collaboration dynamics may be key to understanding variations in the performance of MNCH services. This study explored the dynamics of collaboration among frontline health professionals participating in two MNCH coordination structures in a rural South African district. It examined the role and position of actors, the nature of their relationships, and the overall structure of the collaborative network in two sub-districts. METHODS Cross-sectional survey using a social network analysis (SNA) methodology of 42 district and sub district actors involved in MNCH coordination structures. Different domains of collaboration (eg, communication, professional support, innovation) were surveyed at key interfaces (district-sub-district, across service delivery levels, and within teams). RESULTS The overall network structure reflected a predominantly hierarchical mode of clustering of organisational relationships around hospitals and their referring primary healthcare (PHC) facilities. Clusters were linked through (and dependent on) a combination of district MNCH programme and line managers, identified as central connectors or boundary spanners. Overall network density remained low suggesting potential for strengthening collaborative relationships. Within cluster collaborative patterns (inter-professional and across levels) varied, highlighting the significance of small units in district functioning. CONCLUSION SNA provides a mechanism to uncover the nature of relationships and key actors in collaborative dynamics which could point to system strengths and weaknesses. It offers insights on the level of fragmentation within and across small units, and the need to strengthen cohesion and improve collaborative relationships, and ultimately, the delivery of health services.
Collapse
Affiliation(s)
| | | | - Helen Schneider
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa
| |
Collapse
|
5
|
Herawati DMD, Sunjaya DK, Gumilang L, Adistie F, Dewi Judistiani RT, Yuniati T, Handono B. Impact of Point of Care Quality Improvement Training and Coaching on Quality Perceptions of Health Care Workers: Implication for Quality Policy. J Multidiscip Healthc 2022; 15:1887-1899. [PMID: 36072278 PMCID: PMC9442908 DOI: 10.2147/jmdh.s374905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background The quality of infant healthcare service is one of the essential factors in preventing infant mortality. The purpose of the study was to analyze the quality performance in primary healthcare centers (PHC) and hospitals before and after the point of care quality improvement (POCQI) training for Infant Healthcare Services (IHS). Methods This is a mixed-method study design with convergence triangulation strategy, conducted at six public PHCs and four hospitals in two districts of West Java Province, Indonesia. One hundred health care workers (HCWs) were involved for quantitative study at baseline and end of intervention. An additional 40 patients participated as informants for qualitative study. Quantitative data analysis was performed by Rasch modeling and independent t-test for all variables, followed by content analysis for qualitative data. Results There were significant changes in the variables of POCQI skill (mean diff: 5.14, p=0.001), quality improvement (QI) understanding (mean diff: 1.2; p=0.001), and QI engagement (mean diff: 1.7; p=0.001) in the PHC group. Although there was an increase in process and outcome variables, the changes were not significant. There was a significant change in all variables in the hospital group which were outcome (mean diff: 2.32 (p=0.19); POCQI skill (mean diff: 2.80, p=0.001); process (mean diff: 1.48, p= 0.01); QI understanding (mean diff: 1.01; p=0.01), and QI engagement (mean diff: 1.52; p=0.03). Patient perception in the qualitative study showed that PHCs and Hospitals’ services improved. Moreover, health care workers found they have a better understanding of service quality and created quality changes and improved POCQI steps. Conclusion Implementation of POCQI in PHC and hospitals improved the performance of the quality of his, therefore assuring that POCQI is an appropriate approach and tool to be adopted in the policy for strengthening the health system.
Collapse
Affiliation(s)
- Dewi Marhaeni Diah Herawati
- Departement of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Correspondence: Dewi Marhaeni Diah Herawati, Faculty of Medicine, Universitas Padjadjaran, Jalan Eyckman No. 38, Bandung, Indonesia, Tel +62 82126033975, Email
| | - Deni Kurniadi Sunjaya
- Departement of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Lani Gumilang
- Departement of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Fanny Adistie
- Departement of Pediatric Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Tetty Yuniati
- Departement of Pediatric, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Budi Handono
- Departement of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| |
Collapse
|
6
|
Akuze J, Annerstedt KS, Benova L, Chipeta E, Dossou JP, Gross MM, Kidanto H, Marchal B, Alvesson HM, Pembe AB, van Damme W, Waiswa P, Hanson C. Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda. BMC Health Serv Res 2021; 21:1324. [PMID: 34895216 PMCID: PMC8665312 DOI: 10.1186/s12913-021-07155-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/11/2021] [Indexed: 01/01/2023] Open
Abstract
Background Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period. Methods This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial’s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention. Discussion There is evidence that each of the ALERT intervention components improves health providers’ practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions. Trial registration Pan African Clinical Trial Registry (www.pactr.org): PACTR202006793783148. Registered on 17th June 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07155-z.
Collapse
Affiliation(s)
- Joseph Akuze
- Centre of Excellence for Maternal Newborn and Child Health, Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.,Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Effie Chipeta
- College of Medicine, The Centre for Reproductive Health, University of Malawi, Blantyre, Malawi
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Benin
| | - Mechthild M Gross
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - Hussein Kidanto
- Aga Khan University, Medical College, Dar es Salaam, Tanzania
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Wim van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Peter Waiswa
- Centre of Excellence for Maternal Newborn and Child Health, Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | |
Collapse
|
7
|
Westercamp N, Staedke SG, Maiteki-Sebuguzi C, Ndyabakira A, Okiring JM, Kigozi SP, Dorsey G, Broughton E, Hutchinson E, Massoud MR, Rowe AK. Effectiveness of in-service training plus the collaborative improvement strategy on the quality of routine malaria surveillance data: results of a pilot study in Kayunga District, Uganda. Malar J 2021; 20:290. [PMID: 34187489 PMCID: PMC8243434 DOI: 10.1186/s12936-021-03822-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surveillance data are essential for malaria control, but quality is often poor. The aim of the study was to evaluate the effectiveness of the novel combination of training plus an innovative quality improvement method-collaborative improvement (CI)-on the quality of malaria surveillance data in Uganda. METHODS The intervention (training plus CI, or TCI), including brief in-service training and CI, was delivered in 5 health facilities (HFs) in Kayunga District from November 2015 to August 2016. HF teams monitored data quality, conducted plan-do-study-act cycles to test changes, attended periodic learning sessions, and received CI coaching. An independent evaluation was conducted to assess data completeness, accuracy, and timeliness. Using an interrupted time series design without a separate control group, data were abstracted from 156,707 outpatient department (OPD) records, laboratory registers, and aggregated monthly reports (MR) for 4 time periods: baseline-12 months, TCI scale-up-5 months; CI implementation-9 months; post-intervention-4 months. Monthly OPD register completeness was measured as the proportion of patient records with a malaria diagnosis with: (1) all data fields completed, and (2) all clinically-relevant fields completed. Accuracy was the relative difference between: (1) number of monthly malaria patients reported in OPD register versus MR, and (2) proportion of positive malaria tests reported in the laboratory register versus MR. Data were analysed with segmented linear regression modelling. RESULTS Data completeness increased substantially following TCI. Compared to baseline, all-field completeness increased by 60.1%-points (95% confidence interval [CI]: 46.9-73.2%) at mid-point, and clinically-relevant completeness increased by 61.6%-points (95% CI: 56.6-66.7%). A relative - 57.4%-point (95% confidence interval: - 105.5, - 9.3%) change, indicating an improvement in accuracy of malaria test positivity reporting, but no effect on data accuracy for monthly malaria patients, were observed. Cost per additional malaria patient, for whom complete clinically-relevant data were recorded in the OPD register, was $3.53 (95% confidence interval: $3.03, $4.15). CONCLUSIONS TCI improved malaria surveillance completeness considerably, with limited impact on accuracy. Although these results are promising, the intervention's effectiveness should be evaluated in more HFs, with longer follow-up, ideally in a randomized trial, before recommending CI for wide-scale use.
Collapse
Affiliation(s)
- Nelli Westercamp
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA.
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Alex Ndyabakira
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - John Michael Okiring
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Simon P Kigozi
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Grant Dorsey
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
- Department of Medicine, University of California, San Francisco, USA
| | - Edward Broughton
- ASSIST Project, University Research Co., LLC, 5404 Wisconsin Avenue, Suite 600, Chevy Chase, MD, 20815, USA
| | - Eleanor Hutchinson
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - M Rashad Massoud
- ASSIST Project, University Research Co., LLC, 5404 Wisconsin Avenue, Suite 600, Chevy Chase, MD, 20815, USA
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| |
Collapse
|
8
|
Kumar MB, Madan JJ, Auguste P, Taegtmeyer M, Otiso L, Ochieng CB, Muturi N, Mgamb E, Barasa E. Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya. BMJ Glob Health 2021; 6:e002452. [PMID: 33658302 PMCID: PMC7931757 DOI: 10.1136/bmjgh-2020-002452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya. METHODS We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses. RESULTS We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars). CONCLUSIONS This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.
Collapse
Affiliation(s)
- Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jason J Madan
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Peter Auguste
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | | | - Nelly Muturi
- Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Elizabeth Mgamb
- Department of Health, Migori County Government, Migori, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| |
Collapse
|
9
|
Zamboni K, Singh S, Tyagi M, Hill Z, Hanson C, Schellenberg J. Effect of collaborative quality improvement on stillbirths, neonatal mortality and newborn care practices in hospitals of Telangana and Andhra Pradesh, India: evidence from a quasi-experimental mixed-methods study. Implement Sci 2021; 16:4. [PMID: 33413504 PMCID: PMC7788546 DOI: 10.1186/s13012-020-01058-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/19/2020] [Indexed: 12/02/2022] Open
Abstract
Background Improving quality of care is a key priority to reduce neonatal mortality and stillbirths. The Safe Care, Saving Lives programme aimed to improve care in newborn care units and labour wards of 60 public and private hospitals in Telangana and Andhra Pradesh, India, using a collaborative quality improvement approach. Our external evaluation of this programme aimed to evaluate programme effects on implementation of maternal and newborn care practices, and impact on stillbirths, 7- and 28-day neonatal mortality rate in labour wards and neonatal care units. We also aimed to evaluate programme implementation and mechanisms of change. Methods We used a quasi-experimental plausibility design with a nested process evaluation. We evaluated effects on stillbirths, mortality and secondary outcomes relating to adherence to 20 evidence-based intrapartum and newborn care practices, comparing survey data from 29 hospitals receiving the intervention to 31 hospitals expected to receive the intervention later, using a difference-in-difference analysis. We analysed programme implementation data and conducted 42 semi-structured interviews in four case studies to describe implementation and address four theory-driven questions to explain the quantitative results. Results Only 7 of the 29 intervention hospitals were engaged in the intervention for its entire duration. There was no evidence of an effect of the intervention on stillbirths [DiD − 1.3 percentage points, 95% CI − 2.6–0.1], on neonatal mortality at age 7 days [DiD − 1.6, 95% CI − 9–6.2] or 28 days [DiD − 3.0, 95% CI − 12.9—6.9] or on adherence to target evidence-based intrapartum and newborn care practices. The process evaluation identified challenges in engaging leaders; challenges in developing capacity for quality improvement; and challenges in activating mechanisms of change at the unit level, rather than for a few individuals, and in sustaining these through the creation of new social norms. Conclusion Despite careful planning and substantial resources, the intervention was not feasible for implementation on a large scale. Greater focus is required on strategies to engage leadership. Quality improvement may need to be accompanied by clinical training. Further research is also needed on quality improvement using a health systems perspective. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-020-01058-z.
Collapse
Affiliation(s)
- Karen Zamboni
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Samiksha Singh
- Public Health Foundation, India, Kavuri Hills, Madhapur, Hyderabad, India
| | - Mukta Tyagi
- Public Health Foundation, India, Kavuri Hills, Madhapur, Hyderabad, India
| | - Zelee Hill
- Institute for Global Health, University College London, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
10
|
Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020; 10:021008. [PMID: 33425332 PMCID: PMC7759019 DOI: 10.7189/jogh.10.021008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND CARE India designed and implemented a comprehensive, statewide quality improvement (QI) initiative to improve reproductive, maternal, newborn, and child health and nutrition (RMNCHN) services in public facilities in Bihar. We provide a description of this initiative and its key results during 2014-2017. METHODS We reviewed program documents to identify QI strategies employed and ascertain their coverage. We analysed data from: a) two public facility assessments to ascertain the availability of essential equipment and supplies and the distribution of human resources by facility level; b) a four-phase provider mentoring and training intervention covering 319 facilities to examine changes in emergency obstetric and newborn care (EmONC) practices; and c) four state-representative household surveys to explore changes in selected RMNCHN service utilisation by health sector. Associations of interest were ascertained using χ2 tests. RESULTS Thirty-eight District Quality Assurance Committees and QI teams in 98% of facilities were formed to develop an implementation plan for the QI initiative and oversee its execution. QI strategies were to strengthen facilities' infrastructure; build the state's contracting, procurement, and inventory management capacities; rationalise human resources; improve providers' skills; and modernise data systems. Implementation led to facility infrastructure upgrades, improved clinical staff distribution, and higher availability of equipment and supplies over time, especially in higher-level facilities. Following the mentoring and training intervention in facilities offering both basic and comprehensive EmONC, performance of key practices (eg, adequate administration of uterotonics <1 minute after birth, initiation of skin-to-skin care <5 minutes after birth) improved significantly (P < 0.05). CARE India collected program data and assisted with modernising data systems for tracking human resources, supplies, and program progress statewide. Of women seeking antenatal care, the proportion obtaining key screenings (eg, weight, blood pressure measurements) in public facilities increased over time (P < 0.05). A 6-percentage point decline in home deliveries during 2016-2017 was accompanied by a higher increase of deliveries in public than private facilities (5- vs 1-percentage point; P < 0.05). CONCLUSION Substantial advances were made in improving RMNCHN service quality in Bihar. Continued improvement building on the established QI platform is expected and should be guided by data from now functional data systems.
Collapse
Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sanjiv Daulatrao
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Rohini Durbha
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Kaul
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| |
Collapse
|
11
|
Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
12
|
Schneider H, George A, Mukinda F, Tabana H. District Governance and Improved Maternal, Neonatal and Child Health in South Africa: Pathways of Change. Health Syst Reform 2020; 6:e1669943. [PMID: 32040355 DOI: 10.1080/23288604.2019.1669943] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.
Collapse
Affiliation(s)
- Helen Schneider
- School of Public and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa
| | - Asha George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Fidele Mukinda
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| |
Collapse
|
13
|
Manzi F, Marchant T, Hanson C, Schellenberg J, Mkumbo E, Mlaguzi M, Tancred T. Harnessing the health systems strengthening potential of quality improvement using realist evaluation: an example from southern Tanzania. Health Policy Plan 2020; 35:ii9-ii21. [PMID: 33156943 PMCID: PMC7646731 DOI: 10.1093/heapol/czaa128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 11/13/2022] Open
Abstract
Quality improvement (QI) is a problem-solving approach in which stakeholders identify context-specific problems and create and implement strategies to address these. It is an approach that is increasingly used to support health system strengthening, which is widely promoted in Sub-Saharan Africa. However, few QI initiatives are sustained and implementation is poorly understood. Here, we propose realist evaluation to fill this gap, sharing an example from southern Tanzania. We use realist evaluation to generate insights around the mechanisms driving QI implementation. These insights can be harnessed to maximize capacity strengthening in QI and to support its operationalization, thus contributing to health systems strengthening. Realist evaluation begins by establishing an initial programme theory, which is presented here. We generated this through an elicitation approach, in which multiple sources (theoretical literature, a document review and previous project reports) were collated and analysed retroductively to generate hypotheses about how the QI intervention is expected to produce specific outcomes linked to implementation. These were organized by health systems building blocks to show how each block may be strengthened through QI processes. Our initial programme theory draws from empowerment theory and emphasizes the self-reinforcing nature of QI: the more it is implemented, the more improvements result, further empowering people to use it. We identified that opportunities that support skill- and confidence-strengthening are essential to optimizing QI, and thus, to maximizing health systems strengthening through QI. Realist evaluation can be used to generate rich implementation data for QI, showcasing how it can be supported in ‘real-world’ conditions for health systems strengthening.
Collapse
Affiliation(s)
- Fatuma Manzi
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Sweden
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| | - Elibariki Mkumbo
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Mwanaidi Mlaguzi
- Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, UK
| |
Collapse
|
14
|
Peven K, Bick D, Purssell E, Rotevatn TA, Nielsen JH, Taylor C. Evaluating implementation strategies for essential newborn care interventions in low- and low middle-income countries: a systematic review. Health Policy Plan 2020; 35:ii47-ii65. [PMID: 33156939 PMCID: PMC7646733 DOI: 10.1093/heapol/czaa122] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 01/02/2023] Open
Abstract
Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.
Collapse
Affiliation(s)
- Kimberly Peven
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, 57 Waterloo Road, London SE1 8WA, UK
| | - Debra Bick
- Warwick Clinical Trials Unit, University of Warwick, UK
| | - Edward Purssell
- School of Health Sciences, City, University of London, London, UK
| | - Torill Alise Rotevatn
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Jane Hyldgaard Nielsen
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Midwifery, University College of Northern Denmark, Aalborg, Denmark
| | - Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
15
|
Mubiri P, Kajjo D, Okuga M, Marchant T, Peterson S, Waiswa P, Hanson C. Bypassing or successful referral? A population-based study of reasons why women travel far for childbirth in Eastern Uganda. BMC Pregnancy Childbirth 2020; 20:497. [PMID: 32854629 DOI: 10.1186/s12884-020-03194-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Delivery in a facility with a skilled health provider is considered the most important intervention to reduce maternal and early newborn deaths. Providing care close to people’s homes is an important strategy to facilitate equitable access, but many women are known to bypass the closest delivery facility for a higher level one. The aim of this study was to investigate to what extent mothers in rural Uganda bypassed their nearest facility for childbirth care and the determinants for their choice. Methods The study used data collected as part of the Expanded Quality Management Using Information power (EQUIP) study in the Mayuge District of Eastern Uganda between 2011 and 2014. In this study, bypassing was defined as delivering in a health facility that was not the nearest childbirth facility to the mother’s home. Multilevel logistic regression was used to model the relationship between bypassing the nearest health facility for childbirth and the different independent factors. Results Of all women delivering in a health facility, 45% (499/1115) did not deliver in the nearest facility regardless of the level of care. Further, after excluding women who delivered in health centre II (which is not formally equipped to provide childbirth care) and excluding those who were referred or had a caesarean section (because their reasons for bypassing may be different), 29% (204/717) of women bypassed their nearest facility to give birth in another facility, 50% going to the only hospital of the district. The odds of bypassing increased if a mother belonged to highest wealth quintile compared to the lowest quintile (AOR 2.24, 95% CI: 1.12–4.46) and decreased with increase of readiness of score of the nearest facility for childbirth (AOR = 0.84, 95% CI: 0.69–0.99). Conclusions The extent of bypassing the nearest childbirth facility in this rural Ugandan setting was 29%, and was associated primarily with the readiness of the nearest facility to provide care as well as the wealth of the household. These results suggest inequalities in bypassing for better quality care that have important implications for improving Uganda’s maternal and newborn health outcomes.
Collapse
|
16
|
Hagaman AK, Singh K, Abate M, Alemu H, Kefale AB, Bitewulign B, Estifanos AS, Kiflie A, Mulissa Z, Tiyo H, Seman Y, Tadesse MZ, Magge H. The impacts of quality improvement on maternal and newborn health: preliminary findings from a health system integrated intervention in four Ethiopian regions. BMC Health Serv Res 2020; 20:522. [PMID: 32513236 PMCID: PMC7282234 DOI: 10.1186/s12913-020-05391-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 06/02/2020] [Indexed: 11/26/2022] Open
Abstract
Background Quality improvement (QI) methods are effective in improving healthcare delivery using sustainable, collaborative, and cost-effective approaches. Systems-integrated interventions offer promise in terms of producing sustainable impacts on service quality and coverage, but can also improve important data quality and information systems at scale. Methods This study assesses the preliminary impacts of a first phase, quasi-experimental, QI health systems intervention on maternal and neonatal health outcomes in four pilot districts in Ethiopia. The intervention identified, trained, and coached QI teams to develop and test change ideas to improve service delivery. We use an interrupted time-series approach to evaluate intervention effects over 32-months. Facility-level outcome indicators included: proportion of mothers receiving four antenatal care visits, skilled delivery, syphilis testing, early postnatal care, proportion of low birth weight infants, and measures of quality delivery of childbirth services. Results Following the QI health systems intervention, we found a significant increase in the rate of syphilis testing (ß = 2.41, 95% CI = 0.09,4.73). There were also large positive impacts on health worker adherence to safe child birth practices just after birth (ß = 8.22, 95% CI = 5.15, 11.29). However, there were limited detectable impacts on other facility-usage indicators. Findings indicate early promise of systems-integrated QI on the delivery of maternal health services, and increased some service coverage. Conclusions This study preliminarily demonstrates the feasibility of complex, low-cost, health-worker driven improvement interventions that can be adapted in similar settings around the world, though extended follow up time may be required to detect impacts on service coverage. Policy makers and health system workers should carefully consider what these findings mean for scaling QI approaches in Ethiopia and other similar settings.
Collapse
Affiliation(s)
- Ashley K Hagaman
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, 60 College St, New Haven, CT, 06510, USA. .,Carolina Population Center, University of North Carolina at Chapel Hill, 123 W. Franklin St, Chapel Hill, NC, 27516, USA. .,Yale School of Public Health, 135 College St, New Haven, CT, 06510, USA.
| | - Kavita Singh
- Carolina Population Center, University of North Carolina at Chapel Hill, 123 W. Franklin St, Chapel Hill, NC, 27516, USA.,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Mehiret Abate
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia
| | - Haregeweyni Alemu
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia
| | - Abera Biadgo Kefale
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia
| | - Befikadu Bitewulign
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia
| | - Abiy Seifu Estifanos
- Department of Reproductive Health, School of Public Health, Addis Ababa University, Zambia Street, Tikur Anbessa Hospital Building, Lideta Sub-city, Addis Ababa, Ethiopia
| | - Abiyou Kiflie
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia
| | - Zewdie Mulissa
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia
| | - Hillina Tiyo
- Federal Ministry of Health, Ethiopia, Sudan Street, Addis Ababa, Ethiopia
| | - Yakob Seman
- Federal Ministry of Health, Ethiopia, Sudan Street, Addis Ababa, Ethiopia
| | | | - Hema Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia, Addis Ababa, Ethiopia.,Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| |
Collapse
|
17
|
Zamboni K, Baker U, Tyagi M, Schellenberg J, Hill Z, Hanson C. How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implement Sci 2020; 15:27. [PMID: 32366269 PMCID: PMC7199331 DOI: 10.1186/s13012-020-0978-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 03/02/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Quality improvement collaboratives are widely used to improve health care in both high-income and low and middle-income settings. Teams from multiple health facilities share learning on a given topic and apply a structured cycle of change testing. Previous systematic reviews reported positive effects on target outcomes, but the role of context and mechanism of change is underexplored. This realist-inspired systematic review aims to analyse contextual factors influencing intended outcomes and to identify how quality improvement collaboratives may result in improved adherence to evidence-based practices. METHODS We built an initial conceptual framework to drive our enquiry, focusing on three context domains: health facility setting; project-specific factors; wider organisational and external factors; and two further domains pertaining to mechanisms: intra-organisational and inter-organisational changes. We systematically searched five databases and grey literature for publications relating to quality improvement collaboratives in a healthcare setting and containing data on context or mechanisms. We analysed and reported findings thematically and refined the programme theory. RESULTS We screened 962 abstracts of which 88 met the inclusion criteria, and we retained 32 for analysis. Adequacy and appropriateness of external support, functionality of quality improvement teams, leadership characteristics and alignment with national systems and priorities may influence outcomes of quality improvement collaboratives, but the strength and quality of the evidence is weak. Participation in quality improvement collaborative activities may improve health professionals' knowledge, problem-solving skills and attitude; teamwork; shared leadership and habits for improvement. Interaction across quality improvement teams may generate normative pressure and opportunities for capacity building and peer recognition. CONCLUSION Our review offers a novel programme theory to unpack the complexity of quality improvement collaboratives by exploring the relationship between context, mechanisms and outcomes. There remains a need for greater use of behaviour change and organisational psychology theory to improve design, adaptation and evaluation of the collaborative quality improvement approach and to test its effectiveness. Further research is needed to determine whether certain contextual factors related to capacity should be a precondition to the quality improvement collaborative approach and to test the emerging programme theory using rigorous research designs.
Collapse
Affiliation(s)
- Karen Zamboni
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Ulrika Baker
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mukta Tyagi
- Public Health Foundation, Kavuri Hills, Madhapur, Hyderabad, India
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Zelee Hill
- Institute for Global Health, University College London, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
18
|
Esteves Mills J, Flynn E, Cumming O, Dreibelbis R. Determinants of clean birthing practices in low- and middle-income countries: a scoping review. BMC Public Health 2020; 20:602. [PMID: 32357872 PMCID: PMC7195776 DOI: 10.1186/s12889-020-8431-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Infection is a leading cause of maternal and newborn mortality in low- and middle-income countries (LMIC). Clean birthing practices are fundamental to infection prevention efforts, but these are inadequate in LMIC. This scoping study reviews the literature on studies that describe determinants of clean birthing practices of healthcare workers or mothers during the perinatal period in LMIC. Methods We reviewed literature published between January 2000 and February 2018 providing information on behaviour change interventions, behaviours or behavioural determinants during the perinatal period in LMIC. Following a multi-stage screening process, we extracted key data manually from studies. We mapped identified determinants according to the COM-B behavioural framework, which posits that behaviour is shaped by three categories of determinants – capability, opportunity and motivation. Results Seventy-eight studies were included in the review: 47 observational studies and 31 studies evaluating an intervention. 51% had a household or community focus, 28% had a healthcare facility focus and 21% focused on both. We identified 31 determinants of clean birthing practices. Determinants related to clean birthing practices as a generalised set of behaviours featured in 50 studies; determinants related specifically to one or more of six predefined behaviours – commonly referred to as “the six cleans” – featured in 31 studies. Determinants of hand hygiene (n = 13) and clean cord care (n = 11) were most commonly reported. Reported determinants across all studies clustered around psychological capability (knowledge) and physical opportunity (access to resources). However, greater heterogeneity in reported behavioural determinants was found across studies investigating specific clean birthing practices compared to those studying clean birthing as a generalised set of behaviours. Conclusions Efforts to combine clean birthing practices into a single suite of behaviours – such as the “six cleans”– may simplify policy and advocacy efforts. However, each clean practice has a unique set of determinants and understanding what drives or hinders the adoption of these individual practices is critical to designing more effective interventions to improve hygiene behaviours and neonatal and maternal health outcomes in LMIC. Current understanding in this regard remains limited. More theory-grounded formative research is required to understand motivators and social influences across different contexts.
Collapse
Affiliation(s)
- Joanna Esteves Mills
- Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Erin Flynn
- Infection & Immunity, South Australian Health and Medical Research Institute, North Terrace, Adelaide, 5000, Australia
| | - Oliver Cumming
- Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
19
|
Larson E, Mbaruku GM, Cohen J, Kruk ME. Did a quality improvement intervention improve quality of maternal health care? Implementation evaluation from a cluster-randomized controlled study. Int J Qual Health Care 2020; 32:54-63. [PMID: 31829427 PMCID: PMC7172021 DOI: 10.1093/intqhc/mzz126] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 10/14/2019] [Accepted: 11/12/2019] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To test the success of a maternal healthcare quality improvement intervention in actually improving quality. DESIGN Cluster-randomized controlled study with implementation evaluation; we randomized 12 primary care facilities to receive a quality improvement intervention, while 12 facilities served as controls. SETTING Four districts in rural Tanzania. PARTICIPANTS Health facilities (24), providers (70 at baseline; 119 at endline) and patients (784 at baseline; 886 at endline). INTERVENTIONS In-service training, mentorship and supportive supervision and infrastructure support. MAIN OUTCOME MEASURES We measured fidelity with indictors of quality and compared quality between intervention and control facilities using difference-in-differences analysis. RESULTS Quality of care was low at baseline: the average provider knowledge test score was 46.1% (range: 0-75%) and only 47.9% of women were very satisfied with delivery care. The intervention was associated with an increase in newborn counseling (β: 0.74, 95% CI: 0.13, 1.35) but no evidence of change across 17 additional indicators of quality. On average, facilities reached 39% implementation. Comparing facilities with the highest implementation of the intervention to control facilities again showed improvement on only one of the 18 quality indicators. CONCLUSIONS A multi-faceted quality improvement intervention resulted in no meaningful improvement in quality. Evidence suggests this is due to both failure to sustain a high-level of implementation and failure in theory: quality improvement interventions targeted at the clinic-level in primary care clinics with weak starting quality, including poor infrastructure and low provider competence, may not be effective.
Collapse
Affiliation(s)
- Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Jessica Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| |
Collapse
|
20
|
Tiruneh GT, Zemichael NF, Betemariam WA, Karim AM. Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation. PLoS One 2020; 15:e0228137. [PMID: 32023275 PMCID: PMC7001957 DOI: 10.1371/journal.pone.0228137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/08/2020] [Indexed: 12/01/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Gizachew Tadele Tiruneh
- The Last Ten Kilometers (L10K) 2020 Project, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
- * E-mail: (GTT); (AMK)
| | - Nebreed Fesseha Zemichael
- The Last Ten Kilometers (L10K) 2020 Project, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | - Wuleta Aklilu Betemariam
- The Last Ten Kilometers (L10K) 2020 Project, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | - Ali Mehryar Karim
- Bill & Melinda Gates Foundation, Addis Ababa, Ethiopia
- * E-mail: (GTT); (AMK)
| |
Collapse
|
21
|
Tiruneh GT, Shiferaw CB, Worku A. Effectiveness and cost-effectiveness of home-based postpartum care on neonatal mortality and exclusive breastfeeding practice in low-and-middle-income countries: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2019; 19:507. [PMID: 31852432 PMCID: PMC6921506 DOI: 10.1186/s12884-019-2651-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/29/2019] [Indexed: 01/26/2023] Open
Abstract
Background Early postpartum facility discharge negatively impacts mothers’ proper and effective use postnatal care. Cognizant of these facts, home-based postnatal care practices have been promoted to complement facility-based care to reduce neonatal mortality. This systematic review evaluated the effectiveness and cost-effectiveness of home-based postnatal care on exclusive breastfeeding practice and neonatal mortality in low-and-middle-income countries. Methods Randomized trials and quasi-experimental studies were searched from electronic databases including PubMed, Popline, Cochrane Central Register of Controlled Trials and National Health Service Economic Evaluation databases. Random-effects meta-analysis model was used to pool the estimates of the outcomes accounting for the variability among studies. Results We identified 14 trials implementing intervention packages that included preventive and promotive newborn care services, home-based treatment for sick neonates, and community mobilization activities. The pooled analysis indicates that home-based postpartum care reduced neonatal mortally by 24% (risk ratio 0.76; 95% confidence interval 0.62–0.92; 9 trials; n = 93,083; heterogeneity p < .01) with no evidence of publication bias (Egger’s test: Coef. = − 1.263; p = .130). The subgroup analysis suggested that frequent home visits, home visits by community health workers, and community mobilization efforts with home visits, to had better neonatal survival. Likewise, the odds of mothers who exclusively breastfed from the home visit group were about three times higher than the mothers who were in the routine care group (odds ratio: 2.88; 95% confidence interval: 1.57–5.29; 6 trials; n = 20,624 mothers; heterogeneity p < .01), with low possibility of publication bias (Coef. = − 7.870; p = .164). According to the World Health Organization’s Choosing Interventions that are Cost-Effective project recommendations, home-based neonatal care strategy was found to be cost-effective. Conclusions Home visits and community mobilization activities to promote neonatal care practices by community health workers is associated with reduced neonatal mortality, increased practice of exclusive breastfeeding, and cost-effective in improving newborn health outcomes for low-and-middle-income countries. However, a well-designed evaluation study is required to formulate the optimal package and optimal timing of home visits to standardize home-based postnatal interventions.
Collapse
Affiliation(s)
- Gizachew Tadele Tiruneh
- The Last Ten Kilometers (L10K) Project, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia.
| | - Chalachew Bekele Shiferaw
- St. Paul Hospital Millennium Medical College, Birhan Health and Demographic Surveillance System, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| |
Collapse
|
22
|
Pembe AB, Hirose A, Alwy Al‐beity F, Atuhairwe S, Morris JL, Kaharuza F, Marrone G, Hanson C. Rethinking the definition of maternal near‐miss in low‐income countries using data from 104 health facilities in Tanzania and Uganda. Int J Gynaecol Obstet 2019; 147:389-396. [DOI: 10.1002/ijgo.12976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/18/2019] [Accepted: 09/18/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Andrea B. Pembe
- Department of Obstetrics and GynecologyMuhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
- Association of Gynecologists and Obstetricians of Tanzania Dar es Salaam Tanzania
| | - Atsumi Hirose
- Department of Public Health SciencesKarolinska Institutet Stockholm Sweden
- School of Public HealthImperial College London London UK
| | - Fadhlun Alwy Al‐beity
- Department of Obstetrics and GynecologyMuhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
- Association of Gynecologists and Obstetricians of Tanzania Dar es Salaam Tanzania
- Department of Public Health SciencesKarolinska Institutet Stockholm Sweden
| | - Susan Atuhairwe
- Directorate of Obstetrics and GynecologyMulago National Referral Hospital Kampala Uganda
- Association of Obstetricians and Gynecologists of Uganda Kampala Uganda
| | | | - Frank Kaharuza
- Association of Obstetricians and Gynecologists of Uganda Kampala Uganda
- Makerere University School of Public Health Kampala Uganda
| | - Gaetano Marrone
- Department of Public Health SciencesKarolinska Institutet Stockholm Sweden
| | - Claudia Hanson
- Department of Public Health SciencesKarolinska Institutet Stockholm Sweden
- Department of Disease ControlLondon School of Hygiene & Tropical Medicine London UK
| |
Collapse
|
23
|
Garcia-Elorrio E, Rowe SY, Teijeiro ME, Ciapponi A, Rowe AK. The effectiveness of the quality improvement collaborative strategy in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2019; 14:e0221919. [PMID: 31581197 PMCID: PMC6776335 DOI: 10.1371/journal.pone.0221919] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/16/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Quality improvement collaboratives (QICs) have been used to improve health care for decades. Evidence on QIC effectiveness has been reported, but systematic reviews to date have little information from low- and middle-income countries (LMICs). OBJECTIVE To assess the effectiveness of QICs in LMICs. METHODS We conducted a systematic review following Cochrane methods, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for quality of evidence grading, and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement for reporting. We searched published and unpublished studies between 1969 and March 2019 from LMICs. We included papers that compared usual practice with QICs alone or combined with other interventions. Pairs of reviewers independently selected and assessed the risk of bias and extracted data of included studies. To estimate strategy effectiveness from a single study comparison, we used the median effect size (MES) in the comparison for outcomes in the same outcome group. The primary analysis evaluated each strategy group with a weighted median and interquartile range (IQR) of MES values. In secondary analyses, standard random-effects meta-analysis was used to estimate the weighted mean MES and 95% confidence interval (CI) of the mean MES of each strategy group. This review is registered with PROSPERO (International Prospective Register of Systematic Reviews): CRD42017078108. RESULTS Twenty-nine studies were included; most (21/29, 72.4%) were interrupted time series studies. Evidence quality was generally low to very low. Among studies involving health facility-based health care providers (HCPs), for "QIC only", effectiveness varied widely across outcome groups and tended to have little effect for patient health outcomes (median MES less than 2 percentage points for percentage and continuous outcomes). For "QIC plus training", effectiveness might be very high for patient health outcomes (for continuous outcomes, median MES 111.6 percentage points, range: 96.0 to 127.1) and HCP practice outcomes (median MES 52.4 to 63.4 percentage points for continuous and percentage outcomes, respectively). The only study of lay HCPs, which used "QIC plus training", showed no effect on patient care-seeking behaviors (MES -0.9 percentage points), moderate effects on non-care-seeking patient behaviors (MES 18.7 percentage points), and very large effects on HCP practice outcomes (MES 50.4 percentage points). CONCLUSIONS The effectiveness of QICs varied considerably in LMICs. QICs combined with other invention components, such as training, tended to be more effective than QICs alone. The low evidence quality and large effect sizes for QIC plus training justify additional high-quality studies assessing this approach in LMICs.
Collapse
Affiliation(s)
- Ezequiel Garcia-Elorrio
- Healthcare quality and safety department, Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Samantha Y. Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- CDC Foundation, Atlanta, Georgia, United States of America
| | - Maria E. Teijeiro
- Quality Department, Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Escobar, Buenos Aires Province, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Alexander K. Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| |
Collapse
|
24
|
Kim C, Kirunda R, Mubiru F, Rakhmanova N, Wynne L. A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda. Gates Open Res 2019; 3:1481. [PMID: 31392298 PMCID: PMC6650767 DOI: 10.12688/gatesopenres.12973.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2019] [Indexed: 11/20/2022] Open
Abstract
Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention. Methods: We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions. Results: The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled. Conclusions: A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.
Collapse
Affiliation(s)
- Christine Kim
- Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7411, USA
| | | | | | | | - Leigh Wynne
- FHI 360, 359 Blackwell Street #200, Durham, NC, 27701, USA
| |
Collapse
|
25
|
Doyle AM, Mulhern E, Rosen J, Appleford G, Atchison C, Bottomley C, Hargreaves JR, Weinberger M. Challenges and opportunities in evaluating programmes incorporating human-centred design: lessons learnt from the evaluation of Adolescents 360. Gates Open Res 2019; 3:1472. [PMID: 31363715 PMCID: PMC6635668 DOI: 10.12688/gatesopenres.12998.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2019] [Indexed: 11/20/2022] Open
Abstract
Adolescents 360 (A360) is a four-year initiative (2016-2020) to increase 15-19-year-old girls' use of modern contraception in Nigeria, Ethiopia and Tanzania. The innovative A360 approach is led by human-centred design (HCD), combined with social marketing, developmental neuroscience, public health, sociocultural anthropology and youth engagement 'lenses', and aims to create context-specific, youth-driven solutions that respond to the needs of adolescent girls. The A360 external evaluation includes a process evaluation, quasi-experimental outcome evaluation, and a cost-effectiveness study. We reflect on evaluation opportunities and challenges associated with measuring the application and impact of this novel HCD-led design approach. For the process evaluation, participant observations were key to capturing the depth of the fast-paced, highly-iterative HCD process, and to understand decision-making within the design process. The evaluation team had to be flexible and align closely with the work plan of the implementers. The HCD process meant that key information such as intervention components, settings, and eligible populations were unclear and changed over outcome evaluation and cost-effectiveness protocol development. This resulted in a more time-consuming and resource-intensive study design process. As much time and resources went into the creation of a new design approach, separating one-off "creation" costs versus those costs associated with actually implementing the programme was challenging. Opportunities included the potential to inform programmatic decision-making in real-time to ensure that interventions adequately met the contextualized needs in targeted areas. Robust evaluation of interventions designed using HCD, a promising and increasingly popular approach, is warranted yet challenging. Future HCD-based initiatives should consider a phased evaluation, focusing initially on programme theory refinement and process evaluation, and then, when the intervention program details are clearer, following with outcome evaluation and cost-effectiveness analysis. A phased approach would delay the availability of evaluation findings but would allow for a more appropriate and tailored evaluation design.
Collapse
Affiliation(s)
- Aoife M. Doyle
- London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Hanson C, Zamboni K, Prabhakar V, Sudke A, Shukla R, Tyagi M, Singh S, Schellenberg J. Evaluation of the Safe Care, Saving Lives (SCSL) quality improvement collaborative for neonatal health in Telangana and Andhra Pradesh, India: a study protocol. Glob Health Action 2019; 12:1581466. [PMID: 30849300 PMCID: PMC6419630 DOI: 10.1080/16549716.2019.1581466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence-based maternal and newborn health practices. The Safe Care, Saving Lives initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and Andhra Pradesh, India. Objective: We present a protocol for the evaluation of this programme which aims to (a) estimate the effect of the initiative on evidence-based care practices and mortality; (b) evaluate the mechanisms leading to changes in adherence to evidence-based practices, and their relationship with contextual factors; (c) explore the feasibility of scaling-up the approach. Methods: The mixed-method evaluation is based on a plausibility design nested within a phased implementation. The 29 non-randomly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later. We assessed mortality and adherence to evidence-based practices at baseline and endline using abstraction of registers, checklists, observations and interviews in intervention and comparison hospitals. We also explored the mechanisms and drivers of change in adherence to evidence-based practices. Qualitative methods investigated the mechanisms of change in purposefully selected case study hospitals. A readiness assessment complemented the analysis of what works and why. We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage. Thematic analysis was used for the qualitative data. Discussion: This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme. Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence-based practices.
Collapse
Affiliation(s)
- Claudia Hanson
- a Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK.,b Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Karen Zamboni
- a Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK
| | - Vikrant Prabhakar
- c Department of Community Medicine , Adesh Medical College and Hospital , Kurukshetra , India
| | | | - Rajan Shukla
- e Public Health Foundation of India , Kavuri Hills, Madhapur , Hyderabad , India
| | - Mukta Tyagi
- e Public Health Foundation of India , Kavuri Hills, Madhapur , Hyderabad , India
| | - Samiksha Singh
- e Public Health Foundation of India , Kavuri Hills, Madhapur , Hyderabad , India
| | - Joanna Schellenberg
- a Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK
| |
Collapse
|
27
|
Fabbri C, Dutt V, Shukla V, Singh K, Shah N, Powell-Jackson T. The effect of report cards on the coverage of maternal and neonatal health care: a factorial, cluster-randomised controlled trial in Uttar Pradesh, India. Lancet Glob Health 2019; 7:e1097-e1108. [PMID: 31303297 DOI: 10.1016/s2214-109x(19)30254-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 04/25/2019] [Accepted: 05/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Report cards are a prominent strategy to increase the ability of citizens to express their view, improve public accountability, and foster community participation in the provision of health services in low-income and middle-income countries. In India, social accountability interventions that incorporate report cards and community meetings have been implemented at scale, attracting considerable policy attention, but there is little evidence on their effectiveness in improving health. We aimed to evaluate the effect of report cards, which contain information on village-level indicators of maternal and neonatal health care, and participatory meetings targeted at health providers and community members (including local leaders) on the coverage of maternal and neonatal health care in Uttar Pradesh, India. METHODS We conducted a repeated cross-sectional, 2 × 2 factorial, cluster-randomised controlled trial, in which each cluster was a village (rural) or ward (urban). The clusters were randomly assigned to one of four groups: the provider group, in which we shared report cards and held participatory meetings with providers of maternal and neonatal health services; the community group, in which we shared report cards and held participatory meetings with community members (including local leaders); the providers and community group, in which report cards were targeted at both health providers and the community; and the control group, in which report cards were not shared with anyone. We generated these report cards by collating data from household surveys and shared the report cards with the recipients (as determined by their assigned groups) in participatory meetings. The primary outcome was the proportion of women who had at least four antenatal care visits (ie, attended a clinic or were visited at home by a health-care worker) during their last pregnancy. We measured outcomes with cross-sectional household surveys that were taken at baseline, at a first follow-up (after 8 months of the intervention), and at a second follow-up (21 months after the start of the intervention). Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN11070792. FINDINGS We surveyed eligible women for the baseline survey between Jan 13, and Feb 5, 2015. We then randomly assigned 44 clusters to the provider group, 45 clusters to the community group, 45 clusters to the provider and community group, and 44 clusters to the control group. Report cards of collated survey data were provided to recipient groups, as per their random allocation, in October, 2015, and in September, 2016. We ran the first follow-up survey between May 16 and June 10, 2016. We ran the second follow-up survey between June 18 and July 18, 2017. We measured the primary outcome in 3133 women (795 in the provider group, 781 in the community group, 798 in the provider and community group, and 759 in the control group) who gave birth during implementation of the intervention, between Feb 1, 2016, and July 18, 2017 (the end of the second follow-up survey). The report card intervention did not significantly affect the proportion of women who had at least four antenatal care visits (provider vs non-provider: odds ratio 0·85, 95% CI 0·65-1·13; community vs non-community: 0·86, 0·65-1·13). INTERPRETATION Maternal health report cards containing information on village performance, targeted at either the community or health providers, had no detectable effect on the coverage of maternal and neonatal health care. Future research should seek to understand how the content of information and the delivery of report cards affect the success of this type of social accountability intervention. FUNDING Merck Sharp and Dohme.
Collapse
Affiliation(s)
- Camilla Fabbri
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Varun Dutt
- Sambodhi Research and Communications, Noida, Uttar Pradesh, India
| | - Vasudha Shukla
- Sambodhi Research and Communications, Noida, Uttar Pradesh, India
| | - Kultar Singh
- Sambodhi Research and Communications, Noida, Uttar Pradesh, India
| | - Nehal Shah
- Sambodhi Research and Communications, Noida, Uttar Pradesh, India
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| |
Collapse
|
28
|
Kumar MB, Madan JJ, Achieng MM, Limato R, Ndima S, Kea AZ, Chikaphupha KR, Barasa E, Taegtmeyer M. Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries. BMJ Glob Health 2019; 4:e001390. [PMID: 31354971 PMCID: PMC6626522 DOI: 10.1136/bmjgh-2019-001390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/22/2019] [Accepted: 05/25/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Countries aspiring to universal health coverage view close-to-community (CTC) providers as a low-cost means of increasing coverage. However, due to lack of coordination and unreliable funding, the quality of large-scale CTC healthcare provision is highly variable and routine data about service quality are not trustworthy. Quality improvement (QI) approaches are a means of addressing these issues, yet neither the costs nor the budget impact of integrating QI approaches into CTC programme costs have been assessed. Methods This paper examines the costs and budget impact of integrating QI into existing CTC health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. The intervention involved: (1) QI team formation; (2) Phased training interspersed with supportive supervision; which resulted in (3) QI teams independently collecting and analysing data to conduct QI interventions. Project costs were collected using an ingredients approach from a health systems perspective. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios. Results Annualised economic unit costs ranged from $62 in Mozambique to $254 in Ethiopia per CTC provider supervised, driven by the context, type of community health model and the intensity of the intervention. The budget impact of Ministry-led QI for community health is estimated at 0.53% or less of the general government expenditure on health in all countries (and below 0.03% in three of the five countries). Conclusion CTC provision is a key component of healthcare delivery in many settings, so QI has huge potential impact. The impact is difficult to establish conclusively, but as a first step we have provided evidence to assess affordability of QI for community health. Further research is needed to assess whether QI can achieve the level of benefits that would justify the required investment.
Collapse
Affiliation(s)
- Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.,Center for Humanitarian Emergencies, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jason J Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Ralalicia Limato
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Sozinho Ndima
- Community Health Department, University of Eduardo Mondlane, Faculty of Medicine, Maputo, Mozambique
| | - Aschenaki Z Kea
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
| | - Kingsley Rex Chikaphupha
- Health Systems & HIV/AIDS Dept, Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
29
|
Kim C, Kirunda R, Mubiru F, Rakhmanova N, Wynne L. A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda. Gates Open Res 2019; 3:1481. [DOI: 10.12688/gatesopenres.12973.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 11/20/2022] Open
Abstract
Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.Methods:We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions.Results:The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled.Conclusions:A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.
Collapse
|
30
|
Waiswa P, Okuga M, Kabwijamu L, Akuze J, Sengendo H, Aliganyira P, Pirio P, Hanson C, Kaharuza F. Using research priority-setting to guide bridging the implementation gap in countries - a case study of the Uganda newborn research priorities in the SDG era. Health Res Policy Syst 2019; 17:54. [PMID: 31151401 PMCID: PMC6544968 DOI: 10.1186/s12961-019-0459-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/10/2019] [Indexed: 11/17/2022] Open
Abstract
Background One of the greatest challenges that countries face regarding the achievement of the Sustainable Development Goal (SDG) targets for child health regard the actions required to improve neonatal health; these interventions have to be informed by evidence. In view of the persisting high numbers of newborn deaths in Uganda, we aimed to define a locally contextualised national research agenda for newborn health to guide national investments towards SDG targets. Methods We adopted a systematic approach for priority-setting adapted from the Child Health and Nutrition Research Initiative. We identified and listed local newborn researchers and experts in Uganda by reviewing the PubMed database, through a snowballing technique, and engaged the Ministry of Health. Participants were requested to generate at least three research questions. The collated questions were sent to the same expert group to be rated using five criteria, including answerability, scalability, impact, generalisability and speed. Findings Of the 300 researchers and stakeholders contacted, 104 responded (36%) and generated 304 questions. These questions were collated and duplicates removed giving a condensed list of 41 research questions. These questions were then rated by 82 experts. Of the top 15 research questions, 86.7% (13/15) were in the service delivery and 6.7% (1/15) in the development domain, while only 6.7% (1/15) was in the group ‘other’. None of the leading 15 questions was in the discovery domain. Strategies to improve quality of intrapartum care featured high in the responses, while research around care for premature babies was not a perceived focus of research. Conclusions The focus of improved evidence to guide and innovate service delivery, foremost intrapartum care, reflects the importance of this area as accelerated improvement is likely to yield fast and sustained survival gains in the neonatal period and beyond in Uganda. We recommend that other countries adapt a similar approach in defining priority reproductive, maternal, newborn and child health areas for investment in order to accelerate progress towards achieving the SDGs. Electronic supplementary material The online version of this article (10.1186/s12961-019-0459-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda. .,Makerere University, Center of Excellence for Maternal, Newborn and Child Health, Kampala, Uganda. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Monica Okuga
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Makerere University, Center of Excellence for Maternal, Newborn and Child Health, Kampala, Uganda
| | - Lydia Kabwijamu
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Makerere University, Center of Excellence for Maternal, Newborn and Child Health, Kampala, Uganda
| | - Joseph Akuze
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Makerere University, Center of Excellence for Maternal, Newborn and Child Health, Kampala, Uganda.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Patricia Pirio
- Saving Newborn Lives, Save the Children, Kampala, Uganda
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Frank Kaharuza
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Makerere University, Center of Excellence for Maternal, Newborn and Child Health, Kampala, Uganda
| |
Collapse
|
31
|
Doyle AM, Mulhern E, Rosen J, Appleford G, Atchison C, Bottomley C, Hargreaves JR, Weinberger M. Challenges and opportunities in evaluating programmes incorporating human-centred design: lessons learnt from the evaluation of Adolescents 360. Gates Open Res 2019; 3:1472. [PMID: 31363715 PMCID: PMC6635668 DOI: 10.12688/gatesopenres.12998.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 11/20/2022] Open
Abstract
Adolescents 360 (A360) is a four-year initiative (2016-2020) to increase 15-19-year-old girls' use of modern contraception in Nigeria, Ethiopia and Tanzania. The innovative A360 approach is led by human-centred design (HCD), combined with social marketing, developmental neuroscience, public health, sociocultural anthropology and youth engagement 'lenses', and aims to create context-specific, youth-driven solutions that respond to the needs of adolescent girls. The A360 external evaluation includes a process evaluation, quasi-experimental outcome evaluation, and a cost-effectiveness study. We reflect on evaluation opportunities and challenges associated with measuring the application and impact of this novel HCD-led design approach. For the process evaluation, participant observations were key to capturing the depth of the fast-paced, highly-iterative HCD process, and to understand decision-making within the design process. The evaluation team had to be flexible and align closely with the work plan of the implementers. The HCD process meant that key information such as intervention components, settings, and eligible populations were unclear and changed over outcome evaluation and cost-effectiveness protocol development. This resulted in a more time-consuming and resource-intensive study design process. As much time and resources went into the creation of a new design approach, separating one-off "creation" costs versus those costs associated with actually implementing the programme was challenging. Opportunities included the potential to inform programmatic decision-making in real-time to ensure that interventions adequately met the contextualized needs in targeted areas. Robust evaluation of interventions designed using HCD, a promising and increasingly popular approach, is warranted yet challenging. Future HCD-based initiatives should consider a phased evaluation, focusing initially on programme theory refinement and process evaluation, and then, when the intervention program details are clearer, following with outcome evaluation and cost-effectiveness analysis. A phased approach would delay the availability of evaluation findings but would allow for a more appropriate and tailored evaluation design.
Collapse
Affiliation(s)
- Aoife M. Doyle
- London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Shamba D, Tancred T, Hanson C, Wachira J, Manzi F. Delayed illness recognition and multiple referrals: a qualitative study exploring care-seeking trajectories contributing to maternal and newborn illnesses and death in southern Tanzania. BMC Health Serv Res 2019; 19:225. [PMID: 30975142 PMCID: PMC6460539 DOI: 10.1186/s12913-019-4019-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 03/18/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. METHODS We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. RESULTS Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. CONCLUSIONS Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral.
Collapse
Affiliation(s)
- Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania.
| | - Tara Tancred
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.,Department of Public Health Sciences-Global Health, Karolinska Institute, Stockholm, Sweden
| | - Juddy Wachira
- School of Medicine/AMPATH, Moi University, Nairobi, Kenya
| | - Fatuma Manzi
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| |
Collapse
|
33
|
Baker U, Petro A, Marchant T, Peterson S, Manzi F, Bergström A, Hanson C. Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework. PLoS One 2018; 13:e0209092. [PMID: 30566511 PMCID: PMC6300247 DOI: 10.1371/journal.pone.0209092] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Quality Improvement (QI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect. Materials and methods A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARIHS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes. Results Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention’s comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge. Conclusion Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.
Collapse
Affiliation(s)
- Ulrika Baker
- Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden
- * E-mail: ,
| | - Arafumin Petro
- Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Stefan Peterson
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
- Makerere School of Public Health, Kampala, Uganda
- UNICEF, Health Section, Programme Division, New York, United States of America
| | - Fatuma Manzi
- Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania
| | - Anna Bergström
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
- Institute for Global Health, University College London, London, United Kingdom
| | - Claudia Hanson
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| |
Collapse
|
34
|
Willey B, Waiswa P, Kajjo D, Munos M, Akuze J, Allen E, Marchant T. Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods? J Glob Health 2018. [DOI: 10.7189/jogh.06.0207028.010601] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
35
|
Willey B, Waiswa P, Kajjo D, Munos M, Akuze J, Allen E, Marchant T. Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods? J Glob Health 2018; 8:010601. [PMID: 29497508 PMCID: PMC5823029 DOI: 10.7189/jogh.08.010601] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background Improving maternal and newborn health requires improvements in the quality of facility-based care. This is challenging to measure: routine data may be unreliable; respondents in population surveys may be unable to accurately report on quality indicators; and facility assessments lack population level denominators. We explored methods for linking access to skilled birth attendance (SBA) from household surveys to data on provision of care from facility surveys with the aim of estimating population level effective coverage reflecting access to quality care. Methods We used data from Mayuge District, Uganda. Data from household surveys on access to SBA were linked to health facility assessment census data on readiness to provide basic emergency obstetric and newborn care (BEmONC) in the same district. One individual- and two ecological-linking methods were applied. All methods used household survey reports on where care at birth was accessed. The individual-linking method linked this to data about facility readiness from the specific facility where each woman delivered. The first ecological-linking approach used a district-wide mean estimate of facility readiness. The second used an estimate of facility readiness adjusted by level of health facility accessed. Absolute differences between estimates derived from the different linking methods were calculated, and agreement examined using Lin's concordance correlation coefficient. Results A total of 1177 women resident in Mayuge reported a birth during 2012-13. Of these, 664 took place in facilities within Mayuge, and were eligible for linking to the census of the district's 38 facilities. 55% were assisted by a SBA in a facility. Using the individual-linking method, effective coverage of births that took place with an SBA in a facility ready to provide BEmONC was just 10% (95% confidence interval CI 3-17). The absolute difference between the individual- and ecological-level linking method adjusting for facility level was one percentage point (11%), and tests suggested good agreement. The ecological method using the district-wide estimate demonstrated poor agreement. Conclusions The proportion of women accessing appropriately equipped facilities for care at birth is far lower than the coverage of facility delivery. To realise the life-saving potential of health services, countries need evidence to inform actions that address gaps in the provision of quality care. Linking household and facility-based information provides a simple but innovative method for estimating quality of care at the population level. These encouraging findings suggest that linking data sets can result in meaningful evidence even when the exact location of care seeking is not known.
Collapse
Affiliation(s)
- Barbara Willey
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Waiswa
- Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Darious Kajjo
- Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Melinda Munos
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joseph Akuze
- Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Elizabeth Allen
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Tanya Marchant
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
36
|
Mocumbi S, Hanson C, Högberg U, Boene H, von Dadelszen P, Bergström A, Munguambe K, Sevene E. Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment. Reprod Health 2017; 14:147. [PMID: 29126412 PMCID: PMC5681779 DOI: 10.1186/s12978-017-0408-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair. METHODS We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12-49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software. RESULTS Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16-0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed. CONCLUSION This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.
Collapse
Affiliation(s)
- Sibone Mocumbi
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universidade Eduardo Mondlane (UEM), Av. Agostinho Neto 679, 1100, Maputo, Mozambique. .,Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, SE-75185, Uppsala, Sweden.
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavagen 18A, Plan 4, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Ulf Högberg
- Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, SE-75185, Uppsala, Sweden
| | - Helena Boene
- Centro de Investigação em Saúde de Manhiça (CISM), Rua 12, Vila da Manhiça, 1121, Manhiça, Mozambique
| | | | - Anna Bergström
- Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, SE-75185, Uppsala, Sweden.,University College London, Institute for Global Health, Gower St, London, WC1E 6BT, UK
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Rua 12, Vila da Manhiça, 1121, Manhiça, Mozambique.,Department of Public Health, Faculty of Medicine, UEM, Av. Salvador Allende 702 R/C, Maputo, Mozambique
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça (CISM), Rua 12, Vila da Manhiça, 1121, Manhiça, Mozambique.,Department of Physiological Science, Clinical Pharmacology, Faculty of Medicine, UEM, Av. Salvador Allende 702 R/C, Maputo, Mozambique
| | | |
Collapse
|
37
|
Hanson C, Gabrysch S, Mbaruku G, Cox J, Mkumbo E, Manzi F, Schellenberg J, Ronsmans C. Access to maternal health services: geographical inequalities, United Republic of Tanzania. Bull World Health Organ 2017; 95:810-820. [PMID: 29200522 PMCID: PMC5710083 DOI: 10.2471/blt.17.194126] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 10/03/2017] [Accepted: 10/05/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To determine if improved geographical accessibility led to increased uptake of maternity care in the south of the United Republic of Tanzania. Methods In a household census in 2007 and another large household survey in 2013, we investigated 22 243 and 13 820 women who had had a recent live birth, respectively. The proportions calculated from the 2013 data were weighted to account for the sampling strategy. We examined the association between the straight-line distances to the nearest primary health facility or hospital and uptake of maternity care. Findings The percentages of live births occurring in primary facilities and hospitals rose from 12% (2571/22 243) and 29% (6477/22 243), respectively, in 2007 to weighted values of 39% and 40%, respectively, in 2013. Between the two surveys, women living far from hospitals showed a marked gain in their use of primary facilities, but the proportion giving birth in hospitals remained low (20%). Use of four or more antenatal visits appeared largely unaffected by survey year or the distance to the nearest antenatal clinic. Although the overall percentage of live births delivered by caesarean section increased from 4.1% (913/22 145) in the first survey to a weighted value of 6.5% in the second, the corresponding percentages for women living far from hospital were very low in 2007 (2.8%; 35/1254) and 2013 (3.3%). Conclusion For women living in our study districts who sought maternity care, access to primary facilities appeared to improve between 2007 and 2013, however access to hospital care and caesarean sections remained low.
Collapse
Affiliation(s)
- Claudia Hanson
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT England
| | - Sabine Gabrysch
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Godfrey Mbaruku
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Jonathan Cox
- Bill and Melinda Gates Foundation, Seattle, United States of America
| | - Elibariki Mkumbo
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT England
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, England
| |
Collapse
|