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Seruwagi G, English M, Djellouli N, Shawar Y, Mwaba K, Kuddus A, Kyamulabi A, Akter K, Nakidde C, Namakula H, Kinney M, Colbourn T. How to evaluate a multi-country implementation-focused network: Reflections from the Quality of Care Network (QCN) evaluation. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001897. [PMID: 39208232 PMCID: PMC11361611 DOI: 10.1371/journal.pgph.0001897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/03/2024] [Indexed: 09/04/2024]
Abstract
Learning about how to evaluate implementation-focused networks is important as they become more commonly used. This research evaluated the emergence, legitimacy and effectiveness of a multi-country Quality of Care Network (QCN) aiming to improve maternal, newborn and child health (MNCH) outcomes. We examined the QCN global level, national and local level interfaces in four case study countries. This paper presents the evaluation team's reflections on this 3.5 year multi-country, multi-disciplinary project. Specifically, we examine our approach, methodological innovations, lessons learned and recommendations for conducting similar research. We used a reflective methodological approach to draw lessons on our practice while evaluating the QCN. A 'reflections' tool was developed to guide the process, which happened within a period of 2-4 weeks across the different countries. All country research teams held focused 'reflection' meetings to discuss questions in the tool before sharing responses with this paper's lead author. Similarly, the different lead authors of all eight QCN papers convened their writing teams to reflect on the process and share key highlights. These data were thematically analysed and are presented across key themes around the implementation experience including what went well, facilitators and critical methodological adaptations, what can be done better and recommendations for undertaking similar work. Success drivers included the team's global nature, spread across seven countries with members affiliated to nine institutions. It was multi-level in expertise and seniority and highly multidisciplinary including experts in medicine, policy and health systems, implementation research, behavioural sciences and MNCH. Country Advisory Boards provided technical oversight and support. Despite complexities, the team effectively implemented the QCN evaluation. Strong leadership, partnership, communication and coordination were key; as were balancing standardization with in-country adaptation, co-production, flattening hierarchies among study team members and the iterative nature of data collection. Methodological adaptations included leveraging technology which became essential during COVID-19, clear division of roles and responsibilities, and embedding capacity building as both an evaluation process and outcome, and optimizing technology use for team cohesion and quality outputs.
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Affiliation(s)
- Gloria Seruwagi
- Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
- Department of Social Work and Social Administration, School of Social Sciences, Makerere University, Kampala, Uganda
| | - Mike English
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Nehla Djellouli
- Institute for Global Health, University College London, London, United Kingdom
| | - Yusra Shawar
- International Health, John Hopkins University, Baltimore, Maryland, United States of America
| | - Kasonde Mwaba
- Institute for Global Health, University College London, London, United Kingdom
| | - Abdul Kuddus
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Agnes Kyamulabi
- Department of Social Work and Social Administration, School of Social Sciences, Makerere University, Kampala, Uganda
| | - Kohenour Akter
- International Health, John Hopkins University, Baltimore, Maryland, United States of America
| | - Catherine Nakidde
- Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Hilda Namakula
- Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Mary Kinney
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
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Shawar YR, Djellouli N, Akter K, Payne W, Kinney M, Mwaba K, Seruwagi G, English M, Marchant T, Shiffman J, Colbourn T. Factors shaping network emergence: A cross-country comparison of quality of care networks in Bangladesh, Ethiopia, Malawi, and Uganda. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001839. [PMID: 39042649 PMCID: PMC11265678 DOI: 10.1371/journal.pgph.0001839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/06/2024] [Indexed: 07/25/2024]
Abstract
The Quality-of-Care Network (QCN) was conceptualized by the World Health Organization (WHO) and other global partners to facilitate learning on and improve quality of care for maternal and newborn health within and across low and middle-income countries. However, there was significant variance in the speed and extent to which QCN formed in the involved countries. This paper investigates the factors that shaped QCN's differential emergence in Bangladesh, Ethiopia, Malawi, and Uganda. Drawing on network scholarship, we conducted a replicated case study of the four country cases and triangulated several sources of data, including a document review, observations of national-level and district level meetings, and key informant interviews in each country and at the global level. Thematic coding was performed in NVivo 12. We find that QCN emerged most quickly and robustly in Bangladesh, followed by Ethiopia, then Uganda, and slowest and with least institutionalization in Malawi. Factors connected to the policy environment and network features explained variance in network emergence. With respect to the policy environment, pre-existing resources and initiatives dedicated to maternal and newborn health and quality improvement, strong data and health system capacity, and national commitment to advancing on synergistic goals were crucial drivers to QCN's emergence. With respect to the features of the network itself, the embedding of QCN leadership in powerful agencies with pre-existing coordination structures and trusting relationships with key stakeholders, inclusive network membership, and effective individual national and local leadership were also crucial in explaining QCN's speed and quality of emergence across countries. Studying QCN emergence provides critical insights as to why well-intentioned top-down global health networks may not materialize in some country contexts and have relatively quick uptake in others, and has implications for a network's perceived legitimacy and ultimate effectiveness in producing stated objectives.
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Affiliation(s)
- Yusra Ribhi Shawar
- Department of International Health, Bloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, United States of America
- School of Advanced International Studies, John Hopkins University, Washington, District of Columbia, United States of America
| | - Nehla Djellouli
- Institute for Global Health, University College London, London, United Kingdom
| | - Kohenour Akter
- Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Will Payne
- Department of International Health, Bloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, United States of America
| | - Mary Kinney
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Kasonde Mwaba
- Institute for Global Health, University College London, London, United Kingdom
| | - Gloria Seruwagi
- School of Public Health, Makerere University, Kampala, Uganda
| | - Mike English
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Jeremy Shiffman
- Department of International Health, Bloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, United States of America
- School of Advanced International Studies, John Hopkins University, Washington, District of Columbia, United States of America
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
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Iroz CB, Ramaswamy R, Bhutta ZA, Barach P. Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review. BMC Health Serv Res 2024; 24:332. [PMID: 38481226 PMCID: PMC10935959 DOI: 10.1186/s12913-024-10802-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.
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Affiliation(s)
- Cassandra B Iroz
- Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
| | - Rohit Ramaswamy
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Institute for Global Health & Development, The Aga Khan University, South Central Asia, East Africa, UK
| | - Paul Barach
- Thomas Jefferson University, Philadelphia, PA, USA
- Imperial College, London, UK
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Jarawan E, Boiangiu M, Zeng W. Strengthening provider accountability: A scoping review of accountability/monitoring frameworks for quality of RMNCH care. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001968. [PMID: 37943720 PMCID: PMC10635430 DOI: 10.1371/journal.pgph.0001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
Increasing health providers' accountability is an important element in improving quality of care (QoC) for reproductive, maternal, neonatal, and child health (RMNCH), so as to improve health outcomes of the population in many low- and middle-income countries (LMICs). Implemented RMNCH monitoring initiatives vary in their settings, methods of data collection, and indicators selected for monitoring. The purpose of this study is to evaluate the monitoring/accountability frameworks used by key global monitoring initiatives and provide insights for countries to develop context-customized indicators for RMNCH monitoring and accountability in middle-income countries. The authors conducted a scoping review of key global monitoring initiatives on their monitoring/accountability framework and associated indicators. Data was extracted into a spreadsheet template for analysis. Monitoring/accountability frameworks corresponding to the selected global RMNCH initiatives were described, analyzed, and then categorized the monitoring indicators used by the initiatives according to the type of indicators, quality domains, monitoring levels, and type of services. The results showed that all frameworks regarded developing quality indicators and their monitoring as important elements of accountability and emphasized the role of health systems blocks as inputs for QoC. The researchers demonstrated the importance of measuring quality through both condition-specific and general health system indicators. However, given the different purposes of global monitoring initiatives, the indicators they used varied. We found a lack of indicators measuring QoC of reproductive health. In terms of quality domains, the timeliness and efficiency of RMNCH services were neglected, as few of these indicators were selected for monitoring. Global monitoring initiatives provide valuable frameworks for countries to understand which key indicators need to be tracked to achieve global objectives and develop the foundation for their own accountability/monitoring systems. Gaps in quality indicator design and use emphasize countries need to build on what the global initiatives have achieved to systematically examine quality concerns, develop a tailored and effective accountability/monitoring framework, and improve population health.
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Affiliation(s)
- Eva Jarawan
- Department of Global Health, School of Health, Georgetown University, Washington, DC, United States of America
| | - Mara Boiangiu
- Georgetown University, Washington, DC, United States of America
| | - Wu Zeng
- Department of Global Health, School of Health, Georgetown University, Washington, DC, United States of America
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Olaniran AA, Oludipe M, Hill Z, Ogunyemi A, Umar N, Ohiri K, Schellenberg J, Marchant T. From Theory to Implementation: Adaptations to a Quality Improvement Initiative According to Implementation Context. QUALITATIVE HEALTH RESEARCH 2022; 32:646-655. [PMID: 34772295 PMCID: PMC8851672 DOI: 10.1177/10497323211058699] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
As countries continue to invest in quality improvement (QI) initiatives in health facilities, it is important to acknowledge the role of context in implementation. We conducted a qualitative study between February 2019 and January 2020 to explore how a QI initiative was adapted to enable implementation in three facility types: primary health centres, public hospitals and private facilities in Lagos State, Nigeria.Despite a common theory of change, implementation of the initiative needed to be adapted to accommodate the local needs, priorities and organisational culture of each facility type. Across facility types, inadequate human and capital resources constrained implementation and necessitated an extension of the initiative's duration. In public facilities, the local governance structure was adapted to facilitate coordination, but similar adaptations to governance were not possible for private facilities. Our findings highlight the importance of anticipating and planning for the local adaptation of QI initiatives according to implementation environment.
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Affiliation(s)
- Abimbola A. Olaniran
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Abimbola A. Olaniran, Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
| | | | - Zelee Hill
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Adedoyin Ogunyemi
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nasir Umar
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Kelechi Ohiri
- Health Strategy and Delivery Foundation, Lagos, Nigeria
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Berger BO, Strobino DM, Mehrtash H, Bohren MA, Adu-Bonsaffoh K, Leslie HH, Irinyenikan TA, Maung TM, Balde MD, Tunçalp Ö. Development of measures for assessing mistreatment of women during facility-based childbirth based on labour observations. BMJ Glob Health 2021; 5:e004080. [PMID: 34362791 PMCID: PMC8353173 DOI: 10.1136/bmjgh-2020-004080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings. METHODS Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO's multicountry study 'How women are treated during facility-based childbirth' (2016-2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability. RESULTS Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: -0.06-0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between 'high' and 'low' mistreatment levels. CONCLUSION The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.
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Affiliation(s)
- Blair O Berger
- Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Donna M Strobino
- Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hedieh Mehrtash
- Department of Sexual and Reproductive Health and Research, including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Meghan A Bohren
- Centre for Health Equity, University of Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, University of Ghana, Accra, Greater Accra, Ghana
| | - Hannah H Leslie
- Division of Prevention Science, University of California, San Francisco, San Francisco, California, USA
| | | | - Thae Maung Maung
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Mamadou Dioulde Balde
- Cellulle de Recherche en Sante de la Reproduction en Guinee (CERREGUI), University National Hospital-Donka, Conakry, Guinea
| | - Özge Tunçalp
- UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
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Bohren MA, Tunçalp Ö, Miller S. Transforming intrapartum care: Respectful maternity care. Best Pract Res Clin Obstet Gynaecol 2020; 67:113-126. [DOI: 10.1016/j.bpobgyn.2020.02.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/06/2020] [Accepted: 02/13/2020] [Indexed: 11/28/2022]
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Lattof SR, Maliqi B. Private sector delivery of quality care for maternal, newborn and child health in low-income and middle-income countries: a mixed-methods systematic review protocol. BMJ Open 2020; 10:e033141. [PMID: 32071179 PMCID: PMC7045217 DOI: 10.1136/bmjopen-2019-033141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/04/2019] [Accepted: 12/13/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION To accelerate progress to reach the sustainable development goals for ending preventable maternal, newborn and child deaths, it is critical that both the public and private health service delivery systems invest in increasing coverage of interventions to sustainably deliver quality care for mothers, newborns and children at scale. Although various approaches have been successful in high-income countries, little is known about how to effectively engage and sustain private sector involvement in delivering quality care in low-income and middle-income countries. Our systematic review will examine private sector implementation of quality care for maternal, newborn and child health (MNCH) and the impact of this care. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline for protocols. METHODS AND ANALYSIS Following the PRISMA approach, this systematic review will include quantitative, qualitative and mixed-methods studies addressing the provision of quality MNCH care by private sector providers. Eight databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, Web of Science) and two websites will be searched for relevant studies published between 1 January 1995 and 30 June 2019. For inclusion, studies in low-income and middle-income countries must examine at least one of the following critical outcomes: maternal morbidity or mortality, newborn morbidity or mortality, child morbidity or mortality, quality of care, experience of care and service utilisation. Depending on the data, analyses could include meta-analysis, descriptive quantitative statistics, narrative synthesis and thematic synthesis. Quality will be assessed using tools for qualitative and quantitative studies. ETHICS AND DISSEMINATION Formal ethical approval is not required for this research, as the secondary data are not identifiable. Findings from this review will be used to develop models for effective collaboration of the private and public sectors in implementing quality of care for MNCH. In addition to publishing our findings in a peer-reviewed journal, the findings will be shared through the Quality of Care Network, relevant mailing lists, webinars and social media. PROSPERO REGISTRATION NUMBER CRD42019143383.
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Affiliation(s)
- Samantha R Lattof
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Bohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, Thwin SS, Aderoba AK, Vogel JP, Irinyenikan TA, Adeyanju AO, Mon NO, Adu-Bonsaffoh K, Landoulsi S, Guure C, Adanu R, Diallo BA, Gülmezoglu AM, Soumah AM, Sall AO, Tunçalp Ö. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet 2019; 394:1750-1763. [PMID: 31604660 PMCID: PMC6853169 DOI: 10.1016/s0140-6736(19)31992-0] [Citation(s) in RCA: 243] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/08/2019] [Accepted: 08/15/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. METHODS We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. FINDINGS 2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6-8·0) and younger women with some education (OR 1·6, 1·1-2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity. INTERPRETATION More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context. FUNDING United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.
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Affiliation(s)
- Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia; UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Bukola Fawole
- Department of Obstetrics and Gynaecology, National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Mamadou Dioulde Balde
- Cellule de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
| | - Ernest Maya
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Ghana
| | - Soe Soe Thwin
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Adeniyi K Aderoba
- Department of Obstetrics and Gynaecology, Mother and Child Hospital, Oke-Aro, Akure, Ondo State, Nigeria
| | - Joshua P Vogel
- Maternal and Child Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Theresa Azonima Irinyenikan
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, University of Medical Sciences, Ondo, Ondo State, Nigeria; University of Medical Sciences Teaching Hospital, Akure, Ondo State, Nigeria
| | | | - Nwe Oo Mon
- Department of Medical Research, Yangon, Myanmar
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, Unive rsity of Ghana, Accra, Ghana
| | - Sihem Landoulsi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Chris Guure
- Department of Biostatistics, School of Public Health, University of Ghana, Legon-Accra, Ghana
| | - Richard Adanu
- School of Public Health, University of Ghana, Legon-Accra, Ghana
| | - Boubacar Alpha Diallo
- Cellule de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
| | - A Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Anne-Marie Soumah
- Cellule de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
| | - Alpha Oumar Sall
- Cellule de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Hargreaves S, Rustage K, Nellums LB, Bardfield JE, Agins B, Barker P, Massoud MR, Ford NP, Doherty M, Dougherty G, Singh S. Do Quality Improvement Initiatives Improve Outcomes for Patients in Antiretroviral Programs in Low- and Middle-Income Countries? A Systematic Review. J Acquir Immune Defic Syndr 2019; 81:487-496. [PMID: 31149954 PMCID: PMC6738622 DOI: 10.1097/qai.0000000000002085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND There have been a range of quality improvement (QI) and quality assurance initiatives in low- and middle-income countries to improve antiretroviral therapy (ART) treatment outcomes for people living with HIV. To date, these initiatives have not been systematically assessed and little is known about how effective, cost-effective, or sustainable these strategies are in improving clinical outcomes. METHODS We conducted a systematic review adhering to PRISMA guidelines (PROSPERO ID: CRD42017071848), searching PubMed, MEDLINE, Embase, Web of Science, and the Cochrane database of controlled trials for articles reporting on the effectiveness of QI and quality assurance initiatives in HIV programs in low- and middle-income countries in relation to ART uptake, retention in care, adherence, viral load suppression, mortality, and other outcomes including cost-effectiveness and long-term sustainability. RESULTS One thousand eight hundred sixty articles were found, of which 29 were included. QI approaches were categorized as follows: (1) health system approaches using QI methods; (2) QI learning networks including collaboratives; (3) standard-based methods that use QI tools to improve performance gaps; and (4) campaigns using QI methods. The greatest improvements were seen in ART uptake [median increase of 14.0%; interquartile range (IQR) -9.0 to 29.3], adherence [median increase of 22.0% (IQR -7.0 to 25.0)], and viral load suppression [median increase 26.0% (IQR -8.0 to 26.0)]. CONCLUSIONS QI interventions can be effective in improving clinical outcomes; however, there was significant variability, making it challenging to identify which aspects of interventions lead to clinical improvements. Standardizing reporting and assessment of QI initiatives is needed, supported by national quality policies and directorates, and robust research.
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Affiliation(s)
- Sally Hargreaves
- The Insitute for Infection and Immunity, St George's, University of London, London, United Kingdom
- International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Keiran Rustage
- The Insitute for Infection and Immunity, St George's, University of London, London, United Kingdom
- International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Laura B. Nellums
- The Insitute for Infection and Immunity, St George's, University of London, London, United Kingdom
- International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom
| | - Joshua E. Bardfield
- Healthqual, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA
| | - Bruce Agins
- Healthqual, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA
| | - Pierre Barker
- URC, Chevy Chase, MD
- Institute for Healthcare Improvement, Boston, MA
| | | | - Nathan P. Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland; and
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland; and
| | | | - Satvinder Singh
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland; and
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Larson E, Sharma J, Bohren MA, Tunçalp Ö. When the patient is the expert: measuring patient experience and satisfaction with care. Bull World Health Organ 2019; 97:563-569. [PMID: 31384074 PMCID: PMC6653815 DOI: 10.2471/blt.18.225201] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 12/02/2022] Open
Abstract
In 2018, three independent reports were published, emphasizing the need for attention to, and improvements in, quality of care to achieve effective universal health coverage. A key aspect of high quality health care and health systems is that they are person-centred, a characteristic that is at the same time intrinsically important (all individuals have the right to be treated with dignity and respect) and instrumentally important (person-centred care is associated with improved health-care utilization and health outcomes). Following calls to make 2019 a year of action, we provide guidance to policy-makers, researchers and implementers on how they can take on the task of measuring person-centred care. Theoretically, measures of person-centred care allow quality improvement efforts to be evaluated and ensure that health systems are accountable to those they aim to serve. However, in practice, the utility of these measures is limited by lack of clarity and precision in designing and by using measures for different aspects of person-centeredness. We discuss the distinction between two broad categories of measures of patient-centred care: patient experience and patient satisfaction. We frame our discussion of these measures around three key questions: (i) how will the results of this measure be used?; (ii) how will patient subjectivity be accounted for?; and (iii) is this measure validated or tested? By addressing these issues during the design phase, researchers will increase the usability of their measures.
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Affiliation(s)
- Elysia Larson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 655 Huntington Ave. Building II, 4th floor, Boston, MA 02115, United States of America (USA)
| | - Jigyasa Sharma
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Meghan A Bohren
- Centre for Health Equity, University of Melbourne School of Population and Global Health, Melbourne, Australia
| | - Özge Tunçalp
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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12
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Costello A, Naimy Z. Maternal, newborn, child and adolescent health: challenges for the next decade. Int Health 2019; 11:349-352. [DOI: 10.1093/inthealth/ihz051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/13/2019] [Accepted: 05/29/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
The Millennium Development Goals era achieved substantial improvements in the health of women and children. Yet progress was uneven and many women and children still suffer from preventable mortality and morbidity. The United Nations Secretary General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) set out an ambitious ‘survive, thrive and transform’ agenda for countries as they accelerate progress towards the health-related Sustainable Development Goals. This review highlights aspects of ‘survive, thrive and transform’ that have had strong traction globally, namely quality of care and humanitarian settings for ‘survive’, early childhood development and adolescent health for ‘thrive’ and community engagement and a sustainable environment for ‘transform’.
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Affiliation(s)
| | - Zainab Naimy
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
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