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Bhushan H, Ram U, Scott K, Blanchard AK, Kumar P, Agarwal R, Washington R, Ramesh BM. Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India. BMJ Glob Health 2024; 9:e011411. [PMID: 38770806 PMCID: PMC11085693 DOI: 10.1136/bmjgh-2022-011411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/23/2023] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION India's progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions. METHODS The study's mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews. RESULTS India's maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997-1998 and 2017-2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%-94%), quality antenatal care (37%-85%) and institutional delivery (34%-90%) increased, as did caesarean section rates among the poorest tertile (2%-9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005-2012.The 2005-2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women's empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor. CONCLUSION Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study's integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.
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Affiliation(s)
| | - Usha Ram
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Kerry Scott
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Andrea Katryn Blanchard
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Prakash Kumar
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Ritu Agarwal
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- India Health Action Trust, New Delhi, India
| | - Reynold Washington
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- India Health Action Trust, New Delhi, India
| | - Banadakoppa Manjappa Ramesh
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
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Venugopal S, Patil RB, Thukral A, Koganti RA, Kumar Dl V, Sankar MJ, Agarwal R, Verma A, Deorari AK. Feasibility, Sustainability, and Effectiveness of the Implementation of "Facility-Team-Driven" Approach for Improving the Quality of Newborn Care in South India. Indian J Pediatr 2023; 90:974-981. [PMID: 37269503 DOI: 10.1007/s12098-023-04518-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/15/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The primary objective of the study was to assess the feasibility and sustainability of the implementation of the point of care quality improvement (POCQI) methodology for improving the quality of neonatal care at the level 2 special newborn care unit (SNCU). Additional objective was to evaluate the effectiveness of the quality improvement (QI) and preterm baby package training model. METHODS This study was conducted in a level-II SNCU. The study period was divided into baseline; intervention and sustenance phases. The primary outcome i.e., feasibility was defined as completion of training for 80% or more health care professionals (HCPs) through workshops, their attendance in subsequent review meetings and, successful accomplishment of at least two plan-do-study-act (PDSA) cycles in each project. RESULTS Of the total, 1217 neonates were enrolled during the 14 mo study period; 80 neonates in the baseline, 1019 in intervention and 118 in sustenance phases. Feasibility of training was achieved within a month of initiation of intervention phase; 22/24 (92%) nurses and 14/15 (93%) doctors attended the meetings. The outcomes of individual projects suggested an improvement in proportion of neonates being given exclusive breast milk on day 5 (22.8% to 78%); mean difference (95% CI) [55.2 (46.5 to 63.9)]. Neonates on any antibiotics declined, proportion of any enteral feeds on day one and duration of kangaroo mother care (KMC) increased. Proportion of neonates receiving intravenous fluids during phototherapy decreased. CONCLUSIONS The present study demonstrates the feasibility, sustainability, and effectiveness of a facility-team-driven QI approach augmented with capacity building and post-training supportive supervision.
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Affiliation(s)
- S Venugopal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra B Patil
- Department of Pediatrics, Shimoga Medical College, Shivamogga, Karnataka, India
| | - Anu Thukral
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Raja Ashok Koganti
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Vasanth Kumar Dl
- Department of Pediatrics, Shimoga Medical College, Shivamogga, Karnataka, India
| | - M Jeeva Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Agarwal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Verma
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok K Deorari
- Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, Uttarakhand, India.
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Kaplan L, Richert K, Hülsen V, Diba F, Marthoenis M, Muhsin M, Samadi S, Susanti S, Sofyan H, Ichsan I, Vollmer S. Impact of the WHO Safe Childbirth Checklist on safety culture among health workers: A randomized controlled trial in Aceh, Indonesia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001801. [PMID: 37327202 PMCID: PMC10275423 DOI: 10.1371/journal.pgph.0001801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 04/28/2023] [Indexed: 06/18/2023]
Abstract
The World Health Organization (WHO) developed the Safe Childbirth Checklist (SCC) to increase the application of essential birth practices to ultimately reduce perinatal and maternal deaths. We study the effects of the SCC on health workers safety culture, in the framework of a cluster-randomized controlled trial (16 treatment facilities/16 control facilities). We introduced the SCC in combination with a medium intensity coaching in health facilities which already offered at minimum basic emergency obstetric and newborn care (BEMonC). We assess the effects of using the SCC on 14 outcome variables measuring self-perceived information access, information transmission, frequency of errors, workload and access to resources at the facility level. We apply Ordinary Least Square regressions to identify an Intention to Treat Effect (ITT) and Instrumental Variable regressions to determine a Complier Average Causal Effect (CACE). The results suggest that the treatment significantly improved self-assessed attitudes regarding the probability of calling attention to problems with patient care (ITT 0.6945 standard deviations) and the frequency of errors in times of excessive workload (ITT -0.6318 standard deviations). Moreover, self-assessed resource access increased (ITT 0.6150 standard deviations). The other eleven outcomes were unaffected. The findings suggest that checklists can contribute to an improvement in some dimensions of safety culture among health workers. However, the complier analysis also highlights that achieving adherence remains a key challenge to make checklists effective.
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Affiliation(s)
- Lennart Kaplan
- University of Goettingen, Göttingen, Germany
- German Institute of Development and Sustainability, Bonn, Germany
| | | | | | - Farah Diba
- Universitas Syiah Kuala, Banda Aceh, Indonesia
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Hill Z, Keraga D, Kiflie Alemayehu A, Schellenberg J, Magge H, Estifanos A. 'The objective was about not blaming one another': a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia. Health Res Policy Syst 2023; 21:48. [PMID: 37312225 DOI: 10.1186/s12961-023-00986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives are a common approach to improving quality of care. They rely on collaboration across and within health facilities to enable and accelerate quality improvement. Originating in high-income settings, little is known about how collaboration transfers to low-income settings, despite the widespread use of these collaboratives. METHOD We explored collaboration within quality improvement collaboratives in Ethiopia through 42 in-depth interviews with staff of two hospitals and four health centers and three with quality improvement mentors. Data were analysed thematically using a deductive and inductive approach. RESULTS There was collaboration at learning sessions though experience sharing, co-learning and peer pressure. Respondents were used to a blaming environment, which they contrasted to the open and non-blaming environment at the learning sessions. Respondents formed new relationships that led to across facility practical support. Within facilities, those in the quality improvement team continued to collaborate through the plan-do-study-act cycles, although this required high engagement and support from mentors. Few staff were able to attend learning sessions and within facility transfer of quality improvement knowledge was rare. This affected broader participation and led to some resentment and resistance. Improved teamwork skills and behaviors occurred at individual rather than facility or systems level, with implications for sustainability. Challenges to collaboration included unequal participation, lack of knowledge transfer, high workloads, staff turnover and a culture of dependency. CONCLUSION We conclude that collaboration can occur and is valued within a traditionally hierarchical system, but may require explicit support at learning sessions and by mentors. More emphasis is needed on ensuring quality improvement knowledge transfer, buy-in and system level change. This could include a modified collaborative design to provide facility-level support for spread.
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Affiliation(s)
- Zelee Hill
- Institute for Global Health, University College London, Guilford St, WC1N 1EH, London, United Kingdom.
| | - Dorka Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Hema Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
- Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, United States of America
| | - Abiy Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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Kilbourne AM, Geng E, Eshun-Wilson I, Sweeney S, Shelley D, Cohen DJ, Kirchner JE, Fernandez ME, Parchman ML. How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy. Implement Sci Commun 2023; 4:53. [PMID: 37194084 DOI: 10.1186/s43058-023-00435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Healthcare facilitation, an implementation strategy designed to improve the uptake of effective clinical innovations in routine practice, has produced promising yet mixed results in randomized implementation trials and has not been fully researched across different contexts. OBJECTIVE Using mechanism mapping, which applies directed acyclic graphs that decompose an effect of interest into hypothesized causal steps and mechanisms, we propose a more concrete description of how healthcare facilitation works to inform its further study as a meta-implementation strategy. METHODS Using a modified Delphi consensus process, co-authors developed the mechanistic map based on a three-step process. First, they developed an initial logic model by collectively reviewing the literature and identifying the most relevant studies of healthcare facilitation components and mechanisms to date. Second, they applied the logic model to write vignettes describing how facilitation worked (or did not) based on recent empirical trials that were selected via consensus for inclusion and diversity in contextual settings (US, international sites). Finally, the mechanistic map was created based on the collective findings from the vignettes. FINDINGS Theory-based healthcare facilitation components informing the mechanistic map included staff engagement, role clarification, coalition-building through peer experiences and identifying champions, capacity-building through problem solving barriers, and organizational ownership of the implementation process. Across the vignettes, engagement of leaders and practitioners led to increased socialization of the facilitator's role in the organization. This in turn led to clarifying of roles and responsibilities among practitioners and identifying peer experiences led to increased coherence and sense-making of the value of adopting effective innovations. Increased trust develops across leadership and practitioners through expanded capacity in adoption of the effective innovation by identifying opportunities that mitigated barriers to practice change. Finally, these mechanisms led to eventual normalization and ownership of the effective innovation and healthcare facilitation process. IMPACT Mapping methodology provides a novel perspective of mechanisms of healthcare facilitation, notably how sensemaking, trust, and normalization contribute to quality improvement. This method may also enable more efficient and impactful hypothesis-testing and application of complex implementation strategies, with high relevance for lower-resourced settings, to inform effective innovation uptake.
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Affiliation(s)
- Amy M Kilbourne
- Health Services Research & Development, VA Office of Research and Development, US Department of Veterans Affairs and University of Michigan, 810 Vermont Ave, NW, Washington, D.C., 20420, USA.
| | - Elvin Geng
- Washington University at St. Louis, St. Louis, MO, USA
| | | | | | - Donna Shelley
- New York University School of Global Public Health, New York, New York, USA
| | | | - JoAnn E Kirchner
- Central Arkansas VA Healthcare System and University of Arkansas for Medical Sciences, North Little Rock, AR, USA
| | - Maria E Fernandez
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Procureur F, Estifanos AS, Keraga DW, Kiflie Alemayehu AK, Hailemariam NW, Schellenberg J, Magge H, Hill Z. "Quality teaches you how to use water. It doesn't provide a water pump": a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program. BMC Health Serv Res 2023; 23:381. [PMID: 37076845 PMCID: PMC10116784 DOI: 10.1186/s12913-023-09341-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/25/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives' varied impacts. METHODS To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. RESULTS The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. CONCLUSIONS The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.
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Affiliation(s)
- F Procureur
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK
| | - A S Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - D W Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | - J Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - H Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
- Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston, MA, 02115, USA
| | - Z Hill
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK.
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Asratie MH, Belay DG, Kassie BA, tsega NT, Aragaw FM, Gashaw M, Endalew M. Spatial distribution and determinants of newborn care within 2 days of postpartum period among women with at least one antenatal care visit in Ethiopia: Mixed effect multilevel analysis. PLoS One 2023; 18:e0282012. [PMID: 36854013 PMCID: PMC9974114 DOI: 10.1371/journal.pone.0282012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 02/06/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION Neonatal mortality is pervasive in developing countries like Ethiopia. Though the risk of neonatal mortality is preventable through consolidating simple, low-cost, and less time-consuming essential care, there is a scarcity of evidence about the spatial distribution of newborn care in Ethiopia. OBJECTIVE The current study aimed to demonstrate spatial distribution and determinants of newborn care within 2 days of the postpartum period in Ethiopia. METHODS A cross-sectional study was employed based on Ethiopian demographic and health survey 2016 data and 2796 post-partum period women were included. Arc GIS version 10.7 and SaTScan version 9.6 software were used. Mixed effect analysis was done by STATA version 14 software. Bivariate analysis was done and variables with a p value<0.2 were taken as a candidate for multilevel multivariable logistic regression. Intra Class Correlation Coefficient (ICC), Proportion Change in Variance (PCV), and Median Odds Ratio (MOR) were used for model comparison and an Adjusted Odds Ratio (AOR) with respect to a 95% confidence interval was used for declaring statistical significance. In the multivariable analysis, a p-value≤0.05 was considered as a cut point of statistical significance with the outcome variable. RESULTS The spatial distribution of newborn care was not random and the overall prevalence was 48.39%. Secondary educational level (Adjusted Odds Ratio (AOR = 1.5;95% CI 1.06,2.62), college and above (AOR = 2.47; 95% CI 1.22,5.01), number of antenatal cares three (AOR = 1.5; 95% CI 1.10, 2.04), antenatal care four and above (AOR = 1.6; 95% CI 1.22; 2.19), place of delivery (AOR = 9.67; 7.44, 12.57) and child is a twin (AOR = 3.33; 95% CI 1.23, 9.00) were variables significantly associated with newborn care. CONCLUSIONS Newborn care practice in Ethiopia is below half per hundred participants. Even the distribution was not random. There is a need to pay attention to those cold spot areas and factors significantly associated with newborn care. Improving women's educational levels secondary and above, and consolidating the continuation of antenatal care and health facility delivery were the priority areas to improve newborn care in Ethiopia. Maternal and neonatal health program managers and policymakers should pay attention to those cold spots of newborn care to achieve the sustainable development goal.
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Affiliation(s)
- Melaku Hunie Asratie
- Department of Women’s and Family Health, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Daniel Gashaneh Belay
- Department of Human Anatomy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health sciences, University of Gondar, Gondar, Ethiopia
| | - Belayneh Ayanaw Kassie
- Department of Women’s and Family Health, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nuhamin Tesfa tsega
- Department of Women’s and Family Health, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fantu Mamo Aragaw
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health sciences, University of Gondar, Gondar, Ethiopia
| | - Moges Gashaw
- Department of Physiotherapy, School of Medicine, College of Medicine and Health sciences, University of Gondar, Gondar, Ethiopia
| | - Mastewal Endalew
- Department of Environmental and Occupational Health, and Safety, Institute of Public Health, College of Medicine and Health sciences, University of Gondar, Gondar, Ethiopia
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Jones B, Paterson A, English M, Nagraj S. Improving child health service interventions through a Theory of Change: A scoping review. Front Pediatr 2023; 11:1037890. [PMID: 37090921 PMCID: PMC10115981 DOI: 10.3389/fped.2023.1037890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/16/2023] [Indexed: 04/25/2023] Open
Abstract
Background The objective of this scoping review was to map how child health service interventions develop, utilise, and refine theories of change. A Theory of Change (ToC) is a tool for designing, implementing, and evaluating interventions that is being increasingly used by child health practitioners who are aiming to enact change in health services. Methods A published protocol guided this scoping review. Relevant publications were identified through selected electronic databases and grey literature via a search strategy. The main inclusion criteria were any child health service intervention globally that described their ToC or ToC development process. These were applied by two independent reviewers. Data relevant to the research sub-questions were extracted, charted and discussed. Findings 38 studies were included in the analysis. This scoping review highlights the disparate and inconsistent use, and reporting of ToCs in the child health service intervention literature. Conclusion A ToC may be a helpful tool to enact change in a child health service but careful consideration must be undertaken by the child health service regarding how to maximise the benefits of doing a ToC, and how to accurately report it.
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Affiliation(s)
- Benjamin Jones
- Health Systems Collaborative, Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Correspondence: Benjamin Jones
| | - Amy Paterson
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Health Systems Collaborative, Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, United Kingdom
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shobhana Nagraj
- Health Systems Collaborative, Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, United Kingdom
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Dandona R, Majumder M, Akbar M, Bhattacharya D, Nanda P, Kumar GA, Dandona L. Assessment of quality of antenatal care services in public sector facilities in India. BMJ Open 2022; 12:e065200. [PMID: 36456027 PMCID: PMC9716787 DOI: 10.1136/bmjopen-2022-065200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES We undertook assessment of quality of antenatal care (ANC) services in public sector facilities in the Indian state of Bihar state delivered under the national ANC programme (Pradhan Mantri Surakshit Matritva Abhiyan, PMSMA). SETTING Three community health centres and one subdistrict hospital each in two randomly selected districts of Bihar. PARTICIPANTS Pregnant women who sought ANC services under PMSMA irrespective of the pregnancy trimester. PRIMARY AND SECONDARY MEASURES Quality ANC services were considered if a woman received all of these services in that visit-weight, blood pressure and abdomen check, urine and blood sample taken, and were given iron and folic acid and calcium tablets. The process of ANC service provision was documented. RESULTS Eight hundred and fourteen (94.5% participation) women participated. Coverage of quality ANC services was 30.4% (95% CI 27.3% to 33.7%) irrespective of pregnancy trimester, and was similar in both districts and ranged 3%-83.1% across the facilities. Quality ANC service coverage was significantly lower for women in the first trimester of pregnancy (6.8%, 95% CI 3.3% to 13.6%) as compared with those in the second (34.4%, 95% CI 29.9% to 39.1%) and third (32.9%, 95% CI 27.9% to 38.3%) trimester of pregnancy. Individually, the coverage of weight and blood pressure check-up, receipt of iron folic acid (IFA) and calcium tablets, and blood sample collection was >85%. The coverage of urine sample collection was 46.3% (95% CI 42.9% to 49.7%) and of abdomen check-up was 62% (95% CI 58.6% to 65.3%). Poor information sharing post check-up was done with the pregnant women. Varied implementation of ANC service provision was seen in the facilities as compared with the PMSMA guidelines, in particular with laboratory diagnostics and doctor consultation. Task shifting from doctors to ANMs was observed in all facilities. CONCLUSIONS Grossly inadequate quality ANC services under the PMSMA needs urgent attention to improve maternal and neonatal health outcomes.
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Affiliation(s)
- Rakhi Dandona
- Public Health Foundation of India, Gurugram, Haryana, India
- Department of Health Metrics Sciences, University of Washington, Seattle, Washington, USA
| | | | - Md Akbar
- Public Health Foundation of India, Gurugram, Haryana, India
| | | | - Priya Nanda
- Bill & Melinda Gates Foundation India, New Delhi, India
| | - G Anil Kumar
- Public Health Foundation of India, Gurugram, Haryana, India
| | - Lalit Dandona
- Public Health Foundation of India, Gurugram, Haryana, India
- Department of Health Metrics Sciences, University of Washington, Seattle, Washington, USA
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Williams SJ, Caley L, Davies M, Bird D, Hopkins S, Willson A. Evaluating a quality improvement collaborative: a hybrid approach. J Health Organ Manag 2022; ahead-of-print. [PMID: 36175171 DOI: 10.1108/jhom-11-2021-0397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Quality improvement collaboratives (QICs) are a popular approach to improving healthcare services and patient outcomes. This paper evaluates a QIC implemented by a large, integrated healthcare organisation in Wales in the UK. DESIGN/METHODOLOGY/APPROACH This evaluation study draws on two well-established evaluation frameworks: Kirkpatrick's approach to gather data on participant satisfaction and learning and Stake's approach to gather data and form judgements about the impact of the intervention. A mixed methods approach was taken which included documentary analysis, surveys, semi-structured interviews, and observation of the QIC programme. FINDINGS Together the two frameworks provide a rounded interpretation of the extent to which the QIC intervention was fit-for-purpose. Broadly the evaluation of the QIC was positive with some areas of improvement identified. RESEARCH LIMITATIONS/IMPLICATIONS This study is limited to a QIC conducted within one organisation. Further testing of the hybrid framework is needed that extends to different designs of QICs. PRACTICAL IMPLICATIONS A hybrid framework is provided to assist those charged with designing and evaluating QICs. ORIGINALITY/VALUE Evaluation studies are limited on QICs and if present tend to adopt one framework. Given the complexities of undertaking quality improvement within healthcare, this study uniquely takes a hybrid approach.
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Affiliation(s)
| | - Lynne Caley
- School of Health and Social Care, Swansea University, Swansea, UK
| | - Mandy Davies
- Hywel Dda University Health Board, Carmarthen, UK
| | | | - Sian Hopkins
- Hywel Dda University Health Board, Carmarthen, UK
| | - Alan Willson
- School of Health and Social Care, Swansea University, Swansea, UK
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Abejirinde IOO, Castellano Pleguezuelo V, Benova L, Dossou JP, Hanson C, Metogni CB, Meja S, Mkoka DA, Namazzi G, Sidney K, Marchal B. Strengthening capacity in hospitals to reduce perinatal morbidity and mortality through a codesigned intervention package: protocol for a realist evaluation as part of a stepped-wedge trial of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project. BMJ Open 2022; 12:e057414. [PMID: 35440457 PMCID: PMC9020280 DOI: 10.1136/bmjopen-2021-057414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge-implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthening the capacity of multidisciplinary teams that provide maternity care. The intervention includes competency-based midwife training, community engagement for study design, mentoring and quality improvement cycles. The realist process evaluation of ALERT aims at identifying and testing the causal pathway through which the intervention achieves its impact. METHODS AND ANALYSIS This realist process evaluation complements the effectiveness evaluation and the economic evaluation of the ALERT intervention. Following the realist evaluation cycle, we will first elicit the initial programme theory on the basis of the ALERT theory of change, a review of the evidence on adoption and diffusion of innovations and the perspectives of the stakeholders. Second, we will use a multiple embedded case study design to empirically test the initial programme theory in two hospitals in each of the four intervention countries. Qualitative and quantitative data will be collected, using in-depth interviews with hospital staff and mothers, observations, patient exit interviews and (hospital) document reviews. Analysis will be guided by the Intervention-Actors-Context-Mechanism-Outcome configuration heuristic. We will use thematic coding to analyse the qualitative data. The quantitative data will be analysed descriptively and integrated in the analysis using a retroductive approach. Each case study will end with a refined programme theory (in-case analysis). Third, we will carry out a cross-case comparison within and between the four countries. Comparison between study countries should enable identifying relevant context factors that influence effectiveness and implementation, leading to a mid-range theory that may inform the scaling up the intervention. ETHICS AND DISSEMINATION In developing this protocol, we paid specific attention to cultural sensitivity, the do no harm principle, confidentiality and non-attribution. We received ethical approval from the local and national institutional review boards in Tanzania, Uganda, Malawi, Benin, Sweden and Belgium. Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. The results will be disseminated through workshops with the hospital staff and national policymakers, and scientific publications and conferences. TRIAL REGISTRATION NUMBER PACTR202006793783148.
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Affiliation(s)
- Ibukun-Oluwa Omolade Abejirinde
- International Program Evaluation Unit, Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Social & Behavioural Health Sciences, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Claudia Hanson
- Department of Public Global Health, Karolinska Institute, Stockholm, Sweden
| | | | - Samuel Meja
- University of Malawi College of Medicine, Blantyre, Malawi
| | - D A Mkoka
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gertrude Namazzi
- Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda
| | - Kristi Sidney
- Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Yoon J. Letter to the Editor. Implement Sci Commun 2022; 3:14. [PMID: 35148811 PMCID: PMC8832841 DOI: 10.1186/s43058-022-00266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd, 152-MPD, Menlo Park, CA, 94025, USA. .,HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA.
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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] [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.
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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
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