“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

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

Changes in health worker knowledge and motivation in the context of a quality improvement programme in Ethiopia

A knowledgeable and motivated workforce is critical for health systems to provide high-quality services. Many low- and middle-income countries face shortages in human resources and low health worker motivation but are also home to a burgeoning number of quality improvement (QI) programmes. This study evaluates whether and how motivation and clinical knowledge in three cadres of health workers changed in the context of a QI programme for maternal and newborn health in Ethiopia. This mixed-methods study used a pre-post comparison group design with matched comparison areas. We interviewed 395 health workers at baseline in April 2018 and 404 at endline in June 2019 from seven districts (woredas) with QI and seven comparison woredas. Three cadres were interviewed: health extension workers, facility-based skilled midlevel maternal and newborn care providers, and non-patient-facing staff. A qualitative component sought to triangulate and further elucidate quantitative findings using in-depth interviews with 22 health workers. Motivation was assessed quantitatively, exploratory factor analysis was used to categorize motivation dimensions, and regression-based difference-in-difference analyses were conducted. Knowledge was assessed through a clinical vignette. Qualitative data were analysed in a deductive process based on a framework derived from quantitative results. Although knowledge of the QI programme was high (79%) among participants from QI woreda at endline, participation in QI teams was lower (56%). There was strong evidence that health worker knowledge increased more in areas with QI than comparison areas. Three motivation dimensions emerged from the data: (1) 'helping others', (2) 'pride and satisfaction' and (3) 'external recognition and support'. We found strong evidence that motivation across these factors improved in both QI and comparison areas, with weak evidence of greater increases in comparison areas. Qualitative data suggested the QI programme may have improved motivation by allowing staff to provide better care. This study suggests that although QI programmes can increase health worker knowledge, there may be little effect on motivation. Programme evaluations should measure a wide range of outcomes to fully understand their impact

Mechanical properties of the nanometer scale pre-crystalline order of a poly (ethylene terepthalate) / poly (ethylene naphthalene) blend

A previous study carried out on PET has shown that this polymer undergoes a continuous structural modification over a wide cooling rate interval when solidified from the melt[1] assuming a semi-crystalline structure below 2 K s 1 and a completely amorphous one above 100 K s 1. Most important was the existence of a state of intermediate order between the above cooling rates which was evidenced by the absence of crystalline reflections in the WAXS patterns and the occurrence of SAXS maxima[2] and exothermic peak areas (DSC) in the cooling rate range above 2 K s 1. Microhardness (MH) measurements revealed that this phase affects the mechanical properties[3] plausible if one thinks of crystalline clusters of intermediate order, dispersed in the amorphous polyme

Non-isothermal crystallization kinetics of PET

The crystallization kinetics of poly(ethylene terephthalate) was studied using constant cooling rate, isothermal and quenching experiments. A non-isothermal crystallization kinetics equation based on a single mechanism was used to analyze the data. Different mechanisms of crystallization at low, intermediate, and high cooling rates were hypothesized based on deviation of the experimental data from the single mechanism model

Nanoscale mechanical characterization of polymers by atomic force microscopy (AFM) nanoindentations: Viscoelastic characterization on a model material

The Atomic Force Microscope (AFM), apart form its conventional use as a microscope, is also used for the characterization of the local mechanical properties of polymers. In fact, the elastic characterization of purely elastic materials using this instrument can be considered as a well assessed technique while the challenge remains the characterization of the viscoelastic mechanical properties. In particular, one finds the mechanical behavior changing when performing indentations at different loading rates, i.e., on different time scales. Moreover, this apparent viscoelastic behavior can also be due to complex contact mechanics phenomena, with the onset of plasticity and long-term viscoelastic features which cannot be identified by the force curve alone. For this reason, a viscoelastic characterization, and thus the study of the effects of indentation rate and temperature, were done on model materials where such additional phenomena are not observed. Another time-dependence originating from the instrument itself has also been identified and decoupled. In fact, the viscoelastic behavior has been found to be reproducible even if one changes the experimental set-up as far as the preliminary determinations concerning AFM nanoindentations are well performed. The effects of temperature and time scales on the mechanical behavior have also been undertaken. A check on time-temperature superposition is also attempted through the WLF equation and the apparent activation energies for the elementary motions in the rubbery and in the glass transition regions are in good agreement with the expected values

Role of thermal history on quiescent cold crystallization of PET

8 pags., 9 figs.The cold crystallization of poly(ethylene terephthalate) (PET) has been studied as a function of the initial structure of the glass using density, microhardness, wide angle X-ray scattering, small angle X-ray scattering and DSC measurements. Glassy PET samples varying from slightly crystalline to completely amorphous phase were investigated. Results reveal that differences in the inner structure of the starting glassy material induce different crystallization rates from the glassy amorphous state. Thus, it is observed that crystallization rate decreases with the increasing cooling rate used to quench the samples. Results have been analyzed using the Kolmogroff-Avrami-Evans theory. A good agreement between theoretical and experimental data is obtained providing accurate values for kinetic constants. The different crystallization rates obtained are explained in terms of differences in nucleation density. © 2002 Elsevier Science Ltd. All rights reserved

The continuous cooling transformation (CCT) as a flexible tool to investigate polymer crystallization under processing conditions

An experimental route for investigating polymer crystallization over a wide range of cooling rates (from 0.01 to 1000◦C/s) and pressures (from 0.1 to 40 MPa) is illustrated, using a method that recalls the approach adopted in metallurgy for studying structure development in metals. Two types of experimental setup were used, namely an apparatus for fast cooling of thin films (100–200 μm thick) at various cooling rates under atmospheric pressure and a device (based on a on-purpose modified injection molding machine) for quenching massive samples (about 1–2 cm3) under hydrostatic pressure fields. In both cases, ex situ characterization experiments were carried out to probe the resulting structure, using techniques such as density measurements and wide-angle x-ray diffraction (WAXD) patterns. The cooling mechanism and temperature distribution across the sample thickness were analyzed. Results show that the final structure is determined only by the imposed thermal history and pressure. Experimental results for isotactic polypropylene (iPP), poly(ethylene terephthalate) (PET), polyamide 6 (PA6), and syndiotactic polystyrene (sPS) are reported, showing the reliability of this experimental approach to assess not only quantitative information but also a qualitative description of the crystallization behavior of different classes of semicrystalline polymers. The present study gives an opportunity to evaluate how the combined effect of the cooling rate and pressure influences the crystallization kinetics for various classes of polymer of commercial interest. An increase in the cooling rate translates into a decrease in crystallinity and density, which both experience a sudden drop around the specific “crystallizability” (or “critical cooling rate”) of the material examined. The exception is sPS where competition among the various crystalline modifications determines a minimum in the plot of density vs. cooling rate. As for the effect of pressure, iPP exhibits a “negative dependence” of crystallization kinetics upon pressure, with a decrease of density and degree of crystallinity with increasing pressure, owing to kinetic constraints. PA6 and PET, on the other hand, due to thermodynamic factors resulting in an increase in Tm with pressure, exhibits a “positive dependence” of crystallization kinetics upon pressure. Finally, recent original results concerning sPS have shown that the minimum in the density vs. cooling rate curve shifts toward larger cooling rates upon increasing pressure