Building on momentum from the global campaigns: an exploration of factors that influenced prioritization of stillbirth prevention at the national level in Uganda

Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda

BACKGROUND

There is noted increase in attention towards implementation of evidence-based interventions in response to the stillbirth burden in low- and middle-income countries including Uganda. Recent results reporting some of the strategies adopted have tended to focus much attention towards their overall effect on the stillbirth burden. More is needed regarding stakeholder reflections on priorities and opportunities for delivering quality services within a limited resource setting like Uganda. This paper bridges this knowledge gap.

METHODS

Data collection occurred between March and June 2019 at the national level. Qualitative interviews were analysed using a thematic analysis technique.

RESULTS

Identified priorities included; a focus on supportive functions such as the referral system, attention to the demand side component of maternal health services, and improvements in the support supervision particularly focusing on empowering subnational level actors. The need to strengthen the learning for better implementation of strategies which are compatible with context was also reported. A comprehensive and favourable policy environment with the potential to direct implementation of strategies, harnessing the private sector contribution as well as the role of national level champions and patient advocates to amplify national stillbirth reduction efforts for continued visibility and impact were recommended.

CONCLUSION

Great potential exists within the current strategies to address the national stillbirth burden. However, priorities such as improving the supportive functions of MCH service delivery and attention to the demand side need to be pursued more for better service delivery with opportunities including a favourable policy environment primed to better serve the current strategies. This calls for dedicated efforts targeted at addressing gaps within the existing priorities and opportunities for better delivery of national strategies to address the stillbirth burden in Uganda.

National-level key stakeholders' perspectives regarding intervention progression and emerging challenges within the national stillbirth reduction response in Uganda

INTRODUCTION

Implementation of evidence-based interventions was adopted to respond to the stillbirth burden from the global campaigns. However, new challenges emerge in the process of rolling out such interventions into routine services more so in the context of resource-limited settings. Since the scale-up of policy recommendations to address stillbirth in Uganda, the health system response has seldom been explored. This study was conducted among national-level key stakeholders to elicit their perspectives regarding intervention progression and challenges emerging from the implementation of the national stillbirth reduction strategies in Uganda.

METHODS

The study adopted an exploratory qualitative design with interviews conducted among a purposively selected sample of national-level actors drawn from the maternal and Child Health (MCH) policy networks. Respondents were primed with ongoing national-level stillbirth reduction strategies as a case and later asked for their opinions regarding intervention progression and emerging challenges. All interviews were conducted in English and transcribed verbatim. Atlas. ti was used to facilitate the coding processes which used a pre-determined codebook developed a priori based on the applied framework. A thematic analysis technique was used.

RESULTS

Human resources as reflected in the slow recruitment of essential staff, motivation and attitudes of the available human resource, on and off-drug stockouts, and equipment interruptions posed challenges to the effective implementation of interventions to address the stillbirth burden. The policy translation process was sometimes faced with deviations from the recommended practice. Deviations from guideline implementation, inadequate managerial skills of the health workers and managers in stewarding the implementation processes, inadequate implementation feedback, loops in communication and working with a passive community also posed process-dependent bottlenecks. Outcome expectation challenges stemmed from the inability to deliver stillbirth reduction interventions along the Reproductive Maternal New born Child and Adolescent Health (RMNCAH) continuum of care and the overconcentration of facility-level intervention with less focus on community/demand side interventions.

CONCLUSION

In this exploratory study, national-level stakeholders perceive the adopted stillbirth reduction strategies as having the potential to address the burden. They, however, highlight potential challenges along the input-process-outcome continuum which ought to be addressed and opportunities to explore potential solutions befitting the national-level context.

Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda

Background

The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR).

Methods

The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique.

Results

National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively.

Conclusions

A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.

Evaluation and analysis of anxiety and depression symptoms for college students during COVID-19 pandemic

BACKGROUND

The mental health of students is affected by COVID-19. We aim to evaluate the anxiety and depression symptoms among college students during COVID-19 pandemic, analyze the influence factors that contribute to college students' anxiety and depression symptoms, and provide some suggestions for improving the mental health of college students.

METHODS

With 179 college students participating, an online questionnaire consisting of a general questionnaire, Generalized Anxiety Disorder (GAD-7), and Patient Health Questionnaire (PHQ-9) was conducted in universities in Shanghai. The anxiety and depression symptoms among college students were evaluated using GAD-7 and PHQ-9 scales, and influence factors were analyzed using an unordered multi-class Logistic regression model.

RESULTS

The reliability and validity of the GAD-7 and PHQ-9 scales were good (reliability ≥ 0.9, validity = 100%). The incidence of anxiety was 32.4%, of which were 23.5%, 8.4%, and 0.6% in mild, moderate, and severe, respectively; and the incidence of depression was 46.40%, of which in mild, moderate, moderate to severe, and severe were 28.5%, 10.1%, 7.3%, and 0.6%, respectively. Multivariate analysis revealed that male students with strong psychological quality, who were not easily affected by the COVID-19 pandemic, who received less negative or false information, and who had a strong grasp of psychology and related knowledge were less likely to suffer from mild or moderate anxiety symptoms [OR (95% CI) 0.18 (0.04, 0.81), 0.12 (0.05, 0.33), 0.23 (0.06, 0.89) and 0.07 (0.01, 0.74)]. Furthermore, college students who were not affected by the COVID-19 pandemic were less likely to suffer from mild, moderate, and moderate to severe depression symptoms [OR (95% CI) 0.23 (0.08, 0.65), 0.22 (0.05, 0.93), 0.10 (0.02, 0.54)].

CONCLUSION

The GAD-7 and PHQ-9 scales are suitable for evaluating anxiety and depression symptoms in college students. The COVID-19 pandemic was associated with a high incidence of anxiety and depression symptoms among college students, although gender and mental state fluctuations during the pandemic, negative and false information, and exposure to psychology and related courses were the main influencing factors.

Health workers' social networks and their influence in the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda

Health workers' peer networks are known to influence members' behaviours and practices while translating policies into service delivery. However, little remains known about the extent to which this remains true within interventions aimed at addressing the stillbirth burden in low-resource settings like Uganda. The objective of this study was to examine the health workers' social networks and their influence on the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. A qualitative exploratory design was adopted on a purposively selected sample of 16 key informants. The study was conducted in Mukono district among sub-national health systems, managers, health facility in-charges, and frontline health workers. Data was collected using semi-structured interview guides in a face-to-face interview with respondents. The analysis adopted a thematic approach utilising Atlas. ti software for data management. Participants acknowledged that workplace social networks were influential during the implementation of policies to address stillbirth. The influence exerted was in form of linkage with other services, caution, and advice regarding strict adherence to policy recommendations perhaps reflective of the level of trust in providers' ability to adhere to policy provisions. At the district health management level and among non-state actors, support in perceived areas of weak performance in policy implementation was observed. In addition, timely initiation of contact and subsequent referral was another aspect where health workers exerted influence while translating policies to address the stillbirth burden. While the level of support from among network peers was observed to influence health workers' adoption and implementation of strategies to address the stillbirth burden, different mechanisms triggered subsequent response and level of adherence to recommended policy aspects. Drawing from the elicited responses, we infer that health workers' social networks influence the direction and extent of success in policy implementation to address the stillbirth burden at the subnational level.