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A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda.

ABSTRACT: Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention. Methods: We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions. Results: The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled. Conclusions: A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.

SUBMITTER: Kim C

PROVIDER: S-EPMC6650767 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda.

Kim Christine C Kirunda Ramadhan R Mubiru Frederick F Rakhmanova Nilufar N Wynne Leigh L

Gates open research 20190829

<b>Background</b>: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation ai ...[more]

PMID: 31392298

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Project description:Voluntary, rights-based family planning upholds women's right to determine freely the number and spacing of their children. However, low-resource settings like Uganda still face a high unmet need for family planning. And, while urban areas are often indicated to have better access to health services, emerging evidence is revealing intra-urban socio-economic differentials in family planning utilization. To address the barriers to contraceptive use in these settings, understanding community-specific challenges and involving them in tailored intervention design is crucial. This paper describes the use of co-design, a human-centred design tool, to develop context-specific interventions that promote voluntary family planning in urban settings in Eastern Uganda. A five-stage co-design approach was used: 1) Empathize: primary data was collected to understand the problem and people involved, 2) Define: findings were shared with 56 participants in a three-day in-person co-design workshop, including community members, family planning service providers and leaders, 3) Ideate: workshop participants generated potential solutions, 4) Prototype: participants prioritized prototypes, and 5) Testing: user feedback was sought about the prototypes. A package of ten interventions was developed. Five interventions targeted demand-side barriers to family planning uptake, four targeted supply-side barriers, and one addressed leadership and governance barriers. Involving a diverse group of co-creators provided varied experiences and expertise to develop the interventions. Participants expressed satisfaction with their involvement in finding solutions to challenges in their communities. However, power imbalances and language barriers were identified by the participants as potential barriers to positive group dynamics and discussion quality. To address them, participants were separated into groups, and medical terminologies were simplified during brainstorming sessions. These changes improved participation and maximized the contributions of all participants. It is therefore important to consider participant characteristics and their potential impact on the process, especially when engaging diverse participant groups, and implement measures to mitigate their effects.

Project description:ObjectivesOur objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy.Summary background dataBundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown.MethodsA multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation.ResultsAmong 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001).ConclusionsA comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.

Project description:BackgroundBehavior change interventions have been developed by drawing from many different theories using design processes of varying specificity. We describe the development of a behavior change intervention to improve on-site peri-urban sanitation quality in Lusaka, Zambia using the Behavior Centered Design (BCD) framework to explain the results of the process applied to improving the quality of shared peri-urban sanitation and compare them to similar interventions.MethodsWe used the BCD behavioral determinants model to synthesize the data from our literature review and formative research. Then, we partnered with creative professionals using a design process to develop a theory-driven on-site peri-urban sanitation intervention. Particular attention was paid to the implications of using BCD for intervention development on improving its effectiveness, increasing the contributions to knowledge for other behaviors and settings, and advancing the discipline of applied behavioral science.ResultsBased on findings from a literature review and formative research, we designed an intervention to encourage landlords to improve their toilets by making them more accessible, desirable, hygienic, and sustainable. The intervention involved landlords meeting in facilitated groups every 2 weeks with individual follow-up after each meeting. The meetings presented surprising "hidden camera"-style videos to reveal tenants' perspectives, used participatory activities to help landlords reevaluate the benefits they would derive from improving sanitation on their plots, and provided practical guidance and mechanisms to facilitate the performance of construction and cleaning behaviors.ConclusionsUsing the BCD framework provided an easy-to-follow intervention design process. The resulting intervention is highly creative and multi-faceted, with each element having a theoretical role in an explicit theory of change. The development of this theory-driven intervention advances applied behavioral science by facilitating evaluation of each of the behavior change techniques and the overall delivery mechanism hypothesized to change the target behaviors. This informs the adaptation of these findings to improving on-site sanitation in other settings and the iterative development of the BCD model, which can be used to more effectively change other behaviors.

Project description:BackgroundUnmet need for family planning exceeds 33% in Uganda. One approach to decreasing unmet need is promoting male involvement in family planning. Male disapproval of use of family planning by their female partners and misconceptions about side effects are barriers to family planning globally and in Uganda in particular. Researchers have conducted a number of qualitative studies in recent years to examine different aspects of family planning among Ugandan men. The present study aimed to quantify men's knowledge of family planning in rural Uganda to understand how better to involve men in couples' contraceptive decision-making, particularly in low-resource settings.MethodsData were derived from in-person, researcher-administered surveys of men in a rural agrarian district in Uganda (N =?178). Participant demographics and knowledge of family planning methods, side effects, and use were queried. Descriptive statistics were used for analysis.ResultsMen were 34 years of age on average (range 18-71) and about half (56%) had a primary school education or less. Ninety-eight percent reported any knowledge of family planning, with 73% of men reporting obtaining information via radio and only 43% from health workers. The most common method known by men was the male condom (72%), but more than half also knew of injections (54%) and pills (52%). Relatively few men reported knowing about the most effective reversible contraceptive methods, intrauterine devices and implants (both 16%). Men identified many common contraceptive side-effects, such as vaginal bleeding (31%), and misconceptions about side effects, such as increased risk of infertility and birth defects, were relatively uncommon (both <?10%). About half of all men reported ever using a family planning method (53%), and 40% reported current use.ConclusionsThis study's quantitative results build on those of recent qualitative studies and provide information about the types of family planning information men are lacking and avenues for getting this information to them.

Dataset Information

A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda.

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A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda.

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