‘The objective was about not blaming one another’: a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia

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

Tackling the hard problems: implementation experience and lessons learned in newborn health from the African Health Initiative

Background The Doris Duke Charitable Foundation’s African Health Initiative supported the implementation of Population Health Implementation and Training (PHIT) Partnership health system strengthening interventions in designated areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All PHIT programs included health system strengthening interventions with child health outcomes from the outset, but all increasingly recognized the need to increase focus to improve health and outcomes in the first month of life. This paper uses a case study approach to describe interventions implemented in newborn health, compare approaches, and identify lessons learned across the programs’ collective implementation experience. Methods Case studies were built using quantitative and qualitative methods, applying the World Health Organization Health Systems Strengthening Framework, and maternal, newborn and child health continuum of care framework. We identified the following five primary themes in health systems strengthening intervention strategies used to target improvement in newborn health, which were incorporated by all PHIT projects with varying results: health service delivery at the community level (Tanzania), combining community and health facility level interventions (Zambia), participatory information feedback and clinical training (Ghana), performance review and enhancement (Mozambique), and integrated clinical and system-level improvement (Rwanda), and used individual case studies to illustrate each of these themes. Results Tanzania and Zambia included significant community-based components, including mobilization and sensitization for increased uptake of essential services, while Ghana, Mozambique, and Rwanda focused more efforts on improving the quality of services delivered once a patient enters a health facility. All countries included aspects that improved communication across levels of the health system, whether through district-wide data sharing and peer learning networks in Mozambique and Rwanda, or improved referral processes and systems in Tanzania, Zambia, and Ghana. Conclusion Key lessons learned include the importance of focusing intervention components on addressing drivers of neonatal mortality across the maternal and newborn care continuum at all levels of the health system, matching efforts to improve service utilization with provision of high quality facility-based services, and the critical role of leadership to catalyze improvements in newborn health

Clinical mentorship to improve pediatric quality of care at the health centers in rural Rwanda: a qualitative study of perceptions and acceptability of health care workers

Background: Despite evidence supporting Integrated Management of Childhood Illness (IMCI) as a strategy to improve pediatric care in countries with high child mortality, its implementation faces challenges related to lack of or poor post-didactic training supervision and gaps in necessary supporting systems. These constraints lead to health care workers’ inability to consistently translate IMCI knowledge and skills into practice. A program providing mentoring and enhanced supervision at health centers (MESH), focusing on clinical and systems improvement was implemented in rural Rwanda as a strategy to address these issues, with the ultimate goal of improving the quality of pediatric care at rural health centers. We explored perceptions of MESH from the perspective of IMCI clinical mentors, mentees, and district clinical leadership. Methods: We conducted focus group discussions with 40 health care workers from 21 MESH-supported health centers. Two FGDs in each district were carried out, including one for nurses and one for director of health centers. District medical directors and clinical mentors had individual in-depth interviews. We performed a hermeneutic analysis using Atlas.ti v5.2. Results: Study participants highlighted program components in five key areas that contributed to acceptability and impact, including: 1) Interactive, collaborative capacity-building, 2) active listening and relationships, 3) supporting not policing, 4) systems improvement, and 5) real-time feedback. Staff turn-over, stock-outs, and other facility/systems gaps were identified as barriers to MESH and IMCI implementation. Conclusion: Health care workers reported high acceptance and positive perceptions of the MESH model as an effective strategy to build their capacity, bridge the gap between knowledge and practice in pediatric care, and address facility and systems issues. This approach also improved relationships between the district supervisory team and health center-based care providers. Despite some challenges, many perceived a strong benefit on clinical performance and outcomes. This study can inform program implementers and policy makers of key components needed for developing similar health facility-based mentorship interventions and potential barriers and resistance which can be proactively addressed to ensure success

Consensus-based approach to develop a measurement framework and identify a core set of indicators to track implementation and progress towards effective coverage of facility-based Kangaroo Mother Care.

BACKGROUND: As efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus-based approach to develop a measurement framework and identify a core set of indicators for monitoring facility-based KMC that would be feasible to measure within existing systems. METHODS: The KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face-to-face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions. RESULTS: The KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow-up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility-based KMC, monitoring the quality of KMC, status of babies at discharge from the facility and levels of follow-up (according to country-specific protocol). CONCLUSIONS: These core KMC indicators, identified with input from a wide range of global and country-level KMC and measurement experts, can aid efforts to strengthen monitoring systems and facilitate global tracking of KMC implementation. As data collection systems advance, we encourage program managers and evaluators to document their experiences using this framework to measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country-led data systems

Bubble CPAP to support preterm infants in rural Rwanda: a retrospective cohort study

Background: Complications from premature birth contribute to 35 % of neonatal deaths globally; therefore, efforts to improve clinical outcomes of preterm (PT) infants are imperative. Bubble continuous positive airway pressure (bCPAP) is a low-cost, effective way to improve the respiratory status of preterm and very low birth weight (VLBW) infants. However, bCPAP remains largely inaccessible in resource-limited settings, and information on the scale-up of this technology in rural health facilities is limited. This paper describes health providers’ adherence to bCPAP protocols for PT/VLBW infants and clinical outcomes in rural Rwanda. Methods: This retrospective chart review included all newborns admitted to neonatal units in three rural hospitals in Rwanda between February 1st and October 31st, 2013. Analysis was restricted to PT/VLBW infants. bCPAP eligibility, identification of bCPAP eligibility and complications were assessed. Final outcome was assessed overall and by bCPAP initiation status. Results: There were 136 PT/VLBW infants. For the 135 whose bCPAP eligibility could be determined, 83 (61.5 %) were bCPAP-eligible. Of bCPAP-eligible infants, 49 (59.0 %) were correctly identified by health providers and 43 (51.8 %) were correctly initiated on bCPAP. For the 52 infants who were not bCPAP-eligible, 45 (86.5 %) were correctly identified as not bCPAP-eligible, and 46 (88.5 %) did not receive bCPAP. Overall, 90 (66.2 %) infants survived to discharge, 35 (25.7 %) died, 3 (2.2 %) were referred for tertiary care and 8 (5.9 %) had unknown outcomes. Among the bCPAP eligible infants, the survival rates were 41.8 % (18 of 43) for those in whom the procedure was initiated and 56.5 % (13 of 23) for those in whom it was not initiated. No complications of bCPAP were reported. Conclusion: While the use of bCPAP in this rural setting appears feasible, correct identification of eligible newborns was a challenge. Mentorship and refresher trainings may improve guideline adherence, particularly given high rates of staff turnover. Future research should explore implementation challenges and assess the impact of bCPAP on long-term outcomes

Zinc protoporphyrin and iron deficiency in children: prevalence, trends, and response to therapy in an urban primary care center

Thesis (M.S.)--Boston University PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at [email protected]. Thank you.Background: The American Academy of Pediatrics recommends routine treatment of iron deficiency (ID) due to its potential adverse neurodevelopmental consequences. Optimal testing to diagnose ID without anemia remains unclear. Zinc protoporphyrin (ZPP) has been found to be a valid and inexpensive indicator of ID but is not routinely collected in clinical practices. Evidence suggests that low-income children are at high risk for ID. Objective: To 1) describe the prevalence of ID as measured by ZPP in a low-income population, 2) describe the natural history of ZPP over time, and 3) examine the relationship between iron prescription and ZPP and implications for screening. Design/Methods: This was a retrospective longitudinal study of data from the electronic medical records at Boston Medical Center from 1/1/02 to 12/31/10. Children with a baseline CBC drawn between age 8-18 months and routine screening results for CBC, lead, and ZPP at baseline and follow-up within 2 years were included. Children with sickle cell disease or elevated lead value (≥10 mcg/dL) were excluded. Multivariate logistic regression was used to determine the association between iron prescription and ZPP at follow-up. Results: Ofthe 2612 eligible children, 79% were publicly insured and 65% were Black. Overall, 48% of these children had an abnormal ZPP level (≥35 mcg/dL). Among those with an abnormal ZPP at baseline (n=1254), 18% were prescribed iron. Improvement in ZPP was found in both groups. Iron prescription was significantly associated with improvement in ZPP (OR 1.5, 95% CI 1.1-2.0) and greater mean change in ZPP (p=0.01). In the multivariate analysis, the effect of iron prescription on improvement in ZPP was modified by hemoglobin level. Among those with abnormal ZPP and anemia at baseline (n=189), interim iron prescription was significantly associated with ZPP improvement at follow-up (aOR 2.4, 95% CI 1.1-5.0). Among children without anemia, iron was rarely prescribed and no significant association with ZPP improvement was found. Conclusions: ID, as measured by elevated ZPP , was common in this low-income population, the majority of whom showed improvement at follow-up. Iron prescription was significantly associated with ZPP improvement. Our data suggest that ZPP may be an appropriate method for screening for ID and monitoring response to therapy

Using the Implementation Research Logic Model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia

Abstract Background Community-based treatment of possible serious bacterial infection (PSBI) in young infants, when referral to a hospital is not possible, can result in high treatment coverage and low case fatality. However, in Ethiopia, the coverage of PSBI treatment remains low, worsened by COVID-19. To understand the challenges of delivery of PSBI treatment and design and test adaptative strategies to mitigate the impact of COVID-19 on neonatal mortality, we did implementation research (IR) employing Implementation Research Logic Model (IRLM). In this paper, we describe IRLM application experiences in designing, implementing, and evaluating strategies to improve community-based treatment of PSBI during the COVID-19 pandemic in Ethiopia. Methods This IR was conducted between November 2020-April 2022 at Dembecha and Lume woredas of Amhara and Oromia regions, respectively. We employed narrative reviews, formative assessment and facilitated stakeholder engagement to develop the PSBI treatment IRLM to identify barriers, understand the conceptual linkages among determinants, choose implementation strategies, elicit mechanisms, and link to implementation outcomes. In addition, we used the IRLM to structure the capture of emerging implementation challenges and resulting strategy adaptations throughout implementation. Results This IR identified COVID-19 and multiple pre-existing contextual factors. We designed and implemented implementation strategies to address these challenges. These adaptive strategies were implemented with sufficient strength to maintain the delivery of PSBI services and improve mothers’ care-seeking behavior for their sick young infants. The IRLM offers us a clear process and path to prioritize implementation challenges, choose strategies informed by mechanisms of action, and where the adaptive implementation of community-based management of PSBI would lead to high-implementation fidelity and change in mother behavior to seek care for their sick young infants. The IRLM was also an effective tool for stakeholder engagement, easily explained and used to structure discussion and decision-making during co-design meetings. Conclusions The use of the IRLM helps us to specify the conceptual links between the implementation challenges, strategies, mechanisms of action, and outcomes to explore the complex community-based management of PSBI during complex contexts to improve high-fidelity implementation and integration of PSBI treatment in the primary healthcare delivery systems through active engagement of stakeholders

Economic evaluation of a mentorship and enhanced supervision program to improve quality of integrated management of childhood illness care in rural Rwanda

Background: Integrated management of childhood illness (IMCI) can reduce under-5 morbidity and mortality in low-income settings. A program to strengthen IMCI practices through Mentorship and Enhanced Supervision at Health centers (MESH) was implemented in two rural districts in eastern Rwanda in 2010. Methods: We estimated cost per improvement in quality of care as measured by the difference in correct diagnosis and correct treatment at baseline and 12 months of MESH. Costs of developing and implementing MESH were estimated in 2011 United States Dollars (USD) from the provider perspective using both top-down and bottom-up approaches, from programmatic financial records and site-level data. Improvement in quality of care attributed to MESH was measured through case management observations (n = 292 cases at baseline, 413 cases at 12 months), with outcomes from the intervention already published. Sensitivity analyses were conducted to assess uncertainty under different assumptions of quality of care and patient volume. Results: The total annual cost of MESH was US$27,955.74 and the average cost added by MESH per IMCI patient was US$1.06. Salary and benefits accounted for the majority of total annual costs (US$22,400 /year). Improvements in quality of care after 12 months of MESH implementation cost US$2.95 per additional child correctly diagnosed and $5.30 per additional child correctly treated. Conclusions: The incremental costs per additional child correctly diagnosed and child correctly treated suggest that MESH could be an affordable method for improving IMCI quality of care elsewhere in Rwanda and similar settings. Integrating MESH into existing supervision systems would further reduce costs, increasing potential for spread