Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study

Background: Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories. Objectives: This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes. Methods: To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program. Results: Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered. Conclusions: Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories

"The Actor Is Policy": Application of Elite Theory to Explore Actors' Interests and Power Underlying Maternal Health Policies in Uganda, 2000-2015.

BACKGROUND: The persistence of high maternal mortality and consistent failure in low- and middle-income countries to achieve global targets such as Millennium Development Goal five (MDG 5) is usually explained from epidemiological, interventional and health systems perspectives. The role of policy elites and their interests remains inadequately explored in this debate. This study examined elites and how their interests drove maternal health policies and actions in ways that could explain policy failure for MDG 5 in Uganda. METHODS: We conducted a retrospective qualitative study of Uganda's maternal health policies from 2000 to 2015 (MDG period). Thirty key informant interviews and 2 focus group discussions (FGDs) were conducted with national policy-makers, who directly participated in the formulation of Uganda's maternal health policies during the MDG period. We reviewed 9 National Maternal Health Policy documents. Data were analysed inductively using elite theory. RESULTS: Maternal health policies were mainly driven by a small elite group comprised of Senior Ministry of Health (MoH) officials, some members of cabinet and health development partners (HDPs) who wielded more power than other actors. The resulting policies often appeared to be skewed towards elites' personal political and economic interests, rather than maternal mortality reduction. For a few, however, interests aligned with reducing maternal mortality. Since complying with the government policy-making processes would have exposed elites' personal interests, they mainly drafted policies as service standards and programme documents to bypass the formal policy process. CONCLUSION: Uganda's maternal health policies were mainly influenced by the elites' personal interests rather than by the goal of reducing maternal mortality. This was enabled by the formal guidance for policy-making which gives elites control over the policy process. Accelerating maternal mortality reduction will require re-engineering the policy process to prevent public officials from infusing policies with their interests, and enable percolation of ideas from the public and frontline

The impact of PEPFAR transition on HIV service delivery at health facilities in Uganda.

BackgroundSince 2004, the President's Emergency Plan for AIDS Relief (PEPFAR) has played a large role in Uganda's HIV/AIDS response. To better target resources to high burden regions and facilities, PEPFAR planned to withdraw from 29% of previously-supported health facilities in Uganda between 2015 and 2017.MethodsWe conducted a cross-sectional survey of 226 PEPFAR-supported health facilities in Uganda in mid-2017. The survey gathered information on availability, perceived quality, and access to HIV services before and after transition. We compare responses for facilities transitioned to those maintained on PEPFAR, accounting for survey design. We also extracted data from DHIS2 for the period October 2013-December 2017 on the number of HIV tests and counseling (HTC), number of patients on antiretroviral therapy (Current on ART), and retention on first-line ART (Retention) at 12 months. Using mixed effect models, we compare trends in service volume around the transition period.ResultsThere were 206 facilities that reported transition and 20 that reported maintenance on PEPFAR. Some facilities reporting transition may have been in a gap between implementing partners. The median transition date was September 2016, nine months prior to the survey. Transition facilities were more likely to discontinue HIV outreach following transition (51.6% vs. 1.4%, pConclusionsTransition from PEPFAR resulted in facilities reporting worsening patient access and service quality for HIV care, but there is insufficient evidence to suggest negative impacts on volume of HIV services. Facility respondents' perceptions about access and quality may be overly pessimistic, or they may signal forthcoming impacts. Unrelated to transition, declining retention on ART in Uganda is a cause for concern

Recently graduated midwives in Uganda: Self-perceived achievement, wellbeing and work prospects

Objective: To investigate how recent graduates from a combined work/study midwifery degree programme in Uganda viewed its effects on their wellbeing and work prospects. Design: Using an adapted version of the Qualitative Impact Protocol (QuIP), a phenomenological approach was applied to thematic analysis to examine semi-structured interviews and WhatsApp group discussion. Setting: Introduction of enhanced midwifery training (from Diploma to Degree level) combining study with professional practice within a low income country health system facing extreme capacity constraints. Participants: 14 members of the first cohort of graduates from the degree programme. Findings: The graduates were overwhelmingly positive about improved professional knowledge, clinical skills, confidence, career commitment and prospects. They also had to contend with resentment from colleagues, increased workload and debt. Counselling training, peer support, and experience of managing stress during the training helped them to cope with these challenges. Conclusions: Qualitative feedback from those receiving advanced midwifery training highlights the importance of addressing social as well as technical skills, including leadership capacity and resilience in handling working relationships

Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study

Background: Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories. Objectives: This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes. Methods: To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program. Results: Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered. Conclusions: Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda.

Background: Preventable maternal and newborn deaths remain a global concern, particularly in low- and- middle-income countries (LMICs) Timely maternal death surveillance and response (MDSR) is a recommended strategy to account for such deaths through identifying contextual factors that contributed to the deaths to inform recommendations to implement in order to reduce future deaths. Implementation of MDSR is still suboptimal due to barriers such as inadequate skills and leadership to support MDSR. With the leadership of WHO and UNFPA, there is momentum to roll out MDSR, however, the barriers and enablers for implementation have received limited attention. These have  implications for successful implementation. The aim of this study was: To assess barriers and facilitators to implementation of MDSR at a busy urban National Referral Hospital as perceived by health workers, administrators, and other partners in Reproductive Health. Methods: Qualitative study using in-depth interviews (24), 4 focus-group discussions with health workers, 15 key-informant interviews with health sector managers and implementing partners in Reproductive-Health. We conducted thematic analysis drawing on the Theory of Planned Behaviour (TPB).   Results: The major barriers to implementation of MDSR were: inadequate knowledge and skills; fear of blame / litigation; failure to implement recommendations; burn out because of workload   and inadequate leadership- to support health workers. Major facilitators were involving all health workers in the MDSR process, eliminate blame, strengthen leadership, implement recommendations from MDSR and functionalize lower health facilities (especially Health Centre -IVs). Conclusions: The barriers of MDSR include knowledge and skills gaps, fear of blame and litigation, and other health system factors such as erratic emergency supplies, and leadership/governance challenges. Recommendation: Efforts to strengthen MDSR for impact should use health system responsiveness approach to address the barriers identified, constructive participation of health workers to harness the facilitators and addressing the required legal framework