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Mandu R, Miller L, Namazzi G, Twum-Danso N, Achola KJA, Cooney I, Butrick E, Santos N, Masavah L, Nyakech A, Kirumbi L, Waiswa P, Walker D. Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis. BMJ Open Qual 2023; 12:e002443. [PMID: 38135302 DOI: 10.1136/bmjoq-2023-002443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants' perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER NCT03112018.
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Affiliation(s)
- Rogers Mandu
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
| | - Lara Miller
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Gertrude Namazzi
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
| | | | | | - Isabella Cooney
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
| | | | | | - Leah Kirumbi
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Kampala, Uganda
- Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
- Department of Obstetrics and Gynecology and Global Health Sciences, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
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Anderson R, Zaman SB, Jimmy AN, Read JM, Limmer M. Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review. BMC Pregnancy Childbirth 2023; 23:712. [PMID: 37798690 PMCID: PMC10552246 DOI: 10.1186/s12884-023-06027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND There is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems. METHODS An integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis. RESULTS Fifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers. CONCLUSIONS Effectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization. TRIAL REGISTRATION The protocol is registered in PROSPERO (CRD42022367657).
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Affiliation(s)
- Rondi Anderson
- The Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Sojib Bin Zaman
- Department of Health Sciences, James Madison University, Harrisonburg, Virginia, USA
| | - Abdun Naqib Jimmy
- Environmental Science Department, Jahangirnagar University, Dhaka, Bangladesh
| | - Jonathan M Read
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Mark Limmer
- The Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Smith Hughes C, Butrick E, Namutundu J, Olwanda E, Otieno P, Waiswa P, Walker D, Kahn JG. Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda. PLoS One 2023; 18:e0287309. [PMID: 37352149 PMCID: PMC10289453 DOI: 10.1371/journal.pone.0287309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/02/2023] [Indexed: 06/25/2023] Open
Abstract
INTRODUCTION Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist). METHODS In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2. RESULTS Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries. CONCLUSIONS If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.
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Affiliation(s)
- Carolyn Smith Hughes
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | | | | | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - James G. Kahn
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
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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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Miller L, Wanduru P, Wangia J, Calkins K, Spindler H, Butrick E, Santos N, Kirumbi L, Walker D. Simulation and team training to improve preterm birth knowledge, evidence-based practices, and communication skills in midwives in Kenya and Uganda: Findings from a pre- and post-intervention analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001695. [PMID: 37289721 DOI: 10.1371/journal.pgph.0001695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 05/10/2023] [Indexed: 06/10/2023]
Abstract
Simulation training in basic and emergency obstetric and neonatal care has previously shown success in reducing maternal and neonatal mortality in low-resource settings. Though preterm birth is the leading cause of neonatal deaths, application of this training methodology geared specifically towards reducing preterm birth mortality and morbidity has not yet been implemented and evaluated. The East Africa Preterm Birth Initiative (PTBi-EA) was a multi-country cluster randomized controlled (CRCT) trial that successfully improved outcomes of preterm neonates in Migori County, Kenya and the Busoga region of Uganda through an intrapartum package of interventions. PRONTO simulation and team training (STT) was one component of this package and was introduced to maternity unit providers in 13 facilities. This analysis was nested within the larger CRCT and specifically looked at the impact of the STT portion of the intervention package. The PRONTO STT curriculum was modified to emphasize prematurity-related intrapartum and immediate postnatal care practices, such as assessment of gestational age, identification of preterm labour, and administration of antenatal corticosteroids. Knowledge and communication techniques were assessed at the beginning and end of the intervention through a multiple-choice knowledge test. Clinical skills and communication techniques used in context were assessed through the use of evidence-based practiced (EBPs) as documented in video-recorded simulations through StudioCodeTM video analysis. Pre-and-post scores were compared in both categories using Chi-squared tests. Knowledge assessment scores improved from 51% to 73% with maternal-related questions improving from 61% to 74%, neonatal questions from 55% to 73%, and communication technique questions from 31% to 71%. The portion of indicated preterm birth EBPs performed in simulation increased from 55% to 80% with maternal-related EBPs improving from 48% to 73%, neonatal-related EBPs from 63% to 93%, and communication techniques from 52% to 69%. STT substantially increased preterm birth-specific knowledge and EBPs performed in simulation.
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Affiliation(s)
- Lara Miller
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Phillip Wanduru
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | - Hilary Spindler
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Elizabeth Butrick
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Nicole Santos
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
| | - Leah Kirumbi
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Dilys Walker
- University of California, San Francisco Institute for Global Health Sciences, San Francisco, CA, United States of America
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Nalwadda C, Tusubira AK, Nambuya H, Namazzi G, Muwanguzi D, Waiswa P, Kurinczuk J, Kelley M, Nair M. Transition from hospital to home care for preterm babies: A qualitative study of the experiences of caregivers in Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000528. [PMID: 37155601 PMCID: PMC10166523 DOI: 10.1371/journal.pgph.0000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/14/2023] [Indexed: 05/10/2023]
Abstract
Improving care for preterm babies could significantly increase child survival in low-and middle income countries. However, attention has mainly focused on facility-based care with little emphasis on transition from hospital to home after discharge. Our aim was to understand the experiences of the transition process among caregivers of preterm infants in Uganda in order to improve support systems. A qualitative study among caregivers of preterm infants in Iganga and Jinja districts in eastern Uganda was conducted in June 2019 through February 2020, involving seven focus group discussions and five in-depth interviews. We used thematic-content analysis to identify emergent themes related to the transition process. We included 56 caregivers, mainly mothers and fathers, from a range of socio-demographic backgrounds. Four themes emerged: caregivers' experiences through the transition process from preparation in the hospital to providing care at home; appropriate communication; unmet information needs; and managing community expectations and perceptions. In addition, caregivers' views on 'peer-support' was explored. Caregivers' experiences, and their confidence and ability to provide care were related to preparation in the hospital after birth and until discharge, the information they received and the manner in which healthcare providers communicated. Healthcare workers were a trusted source of information while in the hospital, but there was no continuity of care after discharge which increased their fears and worries about the survival of their infant. They often felt confused, anxious and discouraged by the negative perceptions and expectations from the community. Fathers felt left-out as there was very little communication between them and the healthcare providers. Peer-support could enable a smooth transition from hospital to home care. Interventions to advance preterm care beyond the health facility through a well-supported transition from facility to home care are urgently required to improve health and survival of preterm infants in Uganda and other similar settings.
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Affiliation(s)
- Christine Nalwadda
- Makerere University College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Andrew K Tusubira
- Makerere University College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Gertrude Namazzi
- Makerere University College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Peter Waiswa
- Makerere University College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Jenny Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Maureen Kelley
- The Ethox Centre and Wellcome Centre for Ethics and Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Ghosh R, Otieno P, Butrick E, Santos N, Waiswa P, Walker D. Effect of a quality improvement intervention for management of preterm births on outcomes of all births in Kenya and Uganda: A secondary analysis from a facility-based cluster randomized trial. J Glob Health 2022; 12:04073. [PMID: 36580073 PMCID: PMC9799078 DOI: 10.7189/jogh.12.04073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background A large proportion of early neonatal deaths occur at the time or on the first day of birth. The Preterm Birth Initiative East Africa (PTBi EA) set out to decrease mortality among preterm births through improving quality of facility-based intrapartum care. The PTBi EA cluster randomized trial's primary analysis showed the package reduced intrapartum stillbirth and neonatal death among preterm infants. This secondary analysis examines the impact of the PTBi intervention package on stillbirth and predischarge newborn deaths combined, among all births in 20 participating facilities in Kenya and Uganda. Methods Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention or the control group. All facilities received support for data strengthening and a modified World Health Organization (WHO) Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. We abstracted data from maternity registers. Results Of the total 29 442 births that were included, Kenya had 8468 and 6465 births and Uganda had 8719 and 5790 births, in the control and intervention arms, respectively. There were 935 stillbirths and predischarge newborn deaths in the control arm and 439 in the intervention arm. The adjusted odds ratio (aOR) for the effect of the intervention on the combined outcome, among all births, was 0.96 (95% confidence interval (CI) = 0.69-1.32), which was different by country: Kenya - 1.12 (95% CI = 0.72-1.73); Uganda - 0.65 (95% CI = 0.44-0.98); Pinteraction = 0.025. These trends were similar after excluding the PTBi primary cohort. Conclusions The intervention package improved survival among all births in Uganda but not in Kenya. These results suggest the importance of context and facility differences that were observed between the two countries. Registration This trial is registered with ClinicalTrials.gov, NCT03112018.
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Affiliation(s)
- Rakesh Ghosh
- University of California, San Francisco, Institute for Global Health Sciences, USA
| | - Phelgona Otieno
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Butrick
- University of California, San Francisco, Institute for Global Health Sciences, USA
| | - Nicole Santos
- University of California, San Francisco, Institute for Global Health Sciences, USA
| | - Peter Waiswa
- Makerere University, School of Public Health, Uganda,Department of Global Public Health, Karolinska Institutet, Sweden
| | - Dilys Walker
- University of California, San Francisco, Institute for Global Health Sciences, USA,University of California, San Francisco, School of Medicine, Department of OB/GYN and Reproductive Sciences, USA
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Achola KA, Kajjo D, Santos N, Butrick E, Otare C, Mubiri P, Namazzi G, Merai R, Otieno P, Waiswa P, Walker D. Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda. BMC Health Serv Res 2022; 22:294. [PMID: 35241076 PMCID: PMC8896298 DOI: 10.1186/s12913-022-07650-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background The WHO Safe Childbirth Checklist (SCC) contains 29 evidence-based practices (EBPs) across four pause points spanning admission to discharge. It has been shown to increase EBP uptake and has been tailored to specific contexts. However, little research has been conducted in East Africa on use of the SCC to improve intrapartum care, particularly for preterm birth despite its burden. We describe checklist adaptation, user acceptability, implementation and lessons learned. Methods The East Africa Preterm Birth Initiative (PTBi EA) modified the SCC for use in 23 facilities in Western Kenya and Eastern Uganda as part of a cluster randomized controlled trial evaluating a package of facility-based interventions to improve preterm birth outcomes. The modified SCC (mSCC) for prematurity included: addition of a triage pause point before admission; focus on gestational age assessment, identification and management of preterm labour; and alignment with national guidelines. Following introduction, implementation lasted 24 and 34 months in Uganda and Kenya respectively and was supported through complementary mentoring and data strengthening at all sites. PRONTO® simulation training and quality improvement (QI) activities further supported mSCC use at intervention facilities only. A mixed methods approach, including checklist monitoring, provider surveys and in-depth interviews, was used in this analysis. Results A total of 19,443 and 2229 checklists were assessed in Kenya and Uganda, respectively. In both countries, triage and admission pause points had the highest rates of completion. Kenya’s completion was greater than 70% for all pause points; Uganda ranged from 39 to 75%. Intervention facilities exposed to PRONTO and QI had higher completion rates than control sites. Provider perceptions cited clinical utility of the checklist, particularly when integrated into patient charts. However, some felt it repeated information in other documentation tools. Completion was hindered by workload and staffing issues. Conclusion This study highlights the feasibility and importance of adaptation, iterative modification and complementary activities to reinforce SCC use. There are important opportunities to improve its clinical utility by the addition of prompts specific to the needs of different contexts. The trial assessing the PTBi EA intervention package was registered at ClinicalTrials.gov NCT03112018 Registered December 2016, retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07650-x.
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Affiliation(s)
| | - Darious Kajjo
- Makerere University School of Public Health, Kampala, Uganda
| | - Nicole Santos
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA.
| | | | - Paul Mubiri
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Rikita Merai
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA
| | | | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda.,Department of Global Public Health, Karolinska Institutet, Stockolm, Sweden
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, USA.,Dept. of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, USA
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