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Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study.

ABSTRACT: Multifaceted interventions are important in improving neonatal quality of care and health outcomes. This study describes the implementation of an intervention to improve the quality of newborn care in Solomon Islands, a small island developing state and lower middle-income country in the Western Pacific. Inputs included training, equipment provision, and healthcare system organizational changes. For evaluation, we used a mixed-methods design, using quantitative (audits of health facility equipment, structure, and organization) and qualitative (semi-structured interviews and focused group discussions with healthcare workers) methods. Participants highlighted the practical, interactive, coaching style of training and its short duration as positive features in establishing skills. Training had indirect impacts through improving culture of the workplace, and the evaluation provided a valuable opportunity for reflection of the implementation process for healthcare workers. Facility limitations from equipment deficits and poor condition of clinical areas had implications by limiting the provision of quality care, as well as contributing to healthcare workers feeling undervalued. Resuscitation of a nonbreathing baby was a stressful experience for many health workers, compounded by geographic isolation and feeling unsupported. Our findings highlight the importance of training methodology, impact from structural limitations, and experience of resuscitation for the healthcare worker. Attention to these factors may help the design and implementation of newborn care programs in similar contexts.

SUBMITTER: Tosif S

PROVIDER: S-EPMC7056423 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study.

Tosif Shidan S Jatobatu Anna A Maepioh Anita A Gray Amy A Gilbert Katherine K Hodgson Jan J Duke Trevor T

The American journal of tropical medicine and hygiene 20200301 3

Multifaceted interventions are important in improving neonatal quality of care and health outcomes. This study describes the implementation of an intervention to improve the quality of newborn care in Solomon Islands, a small island developing state and lower middle-income country in the Western Pacific. Inputs included training, equipment provision, and healthcare system organizational changes. For evaluation, we used a mixed-methods design, using quantitative (audits of health facility equipme ...[more]

PMID: 31971147

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Project description:BackgroundThe burden of obesity is high among US veterans, yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE, a home-based, 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services.ObjectiveThe primary aim was to establish preliminary evidence for the program by comparing outcomes for TeleMOVE with standard, facility-based MOVE weight-management services (group, individual modalities) over the evaluation period based on the number of patients enrolled per site and the program's clinical effectiveness, as demonstrated by average weight lost per patient. The secondary aim was to understand factors influencing TeleMOVE implementation variability across demonstration sites to develop recommendations to improve national program dissemination.MethodsWe employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE at 9 demonstration sites and compare patient- and site-level measures of program uptake. Data were collected between October 1, 2009 and September 30, 2011. Patient-level program outcomes were extracted from VHA patient care databases to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared with outcomes for veterans enrolled in standard MOVE! at each demonstration site, as well as with national averages during the first 2 years of program implementation. For the secondary aim, we invited program stakeholders to participate in 2 rounds of semistructured interviews about aspects of TeleMOVE implementation processes, site-level contextual factors, and program delivery. Twenty-eight stakeholders participated in audio-recorded interviews.ResultsAlthough stakeholders at 3 sites declined to be interviewed, objective program uptake was high at 2 sites, delayed-high at 2 sites, and low at 5 sites. At 6 months post enrollment, the mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at -5.2 lb (SD 14.4) and -5.1 lb (SD 12.2), respectively (P=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements, whereas low-uptake sites reported less leadership support and effective communication among stakeholders.ConclusionsThis implementation evaluation of a clinical telehealth program demonstrated the value of partnership-based research in which researchers not only provided operational leaders with feedback regarding the effectiveness of a new program but also relevant feedback into contextual factors related to program implementation to enable adaptations for national deployment efforts.

Project description:BACKGROUND:Newborn mortality in Oceania declined slower than other regions in the past 25?years. The World Health Organization (WHO) introduced the Early Essential Newborn Care program (EENC) in 2015 in Solomon Islands, a Small Island Developing State, to address high newborn mortality. We explored knowledge and skills retention among healthcare workers following EENC coaching. METHODS:Between March 2015 and December 2017, healthcare workers in five hospitals were assessed: pre- and post-clinical coaching and at a later evaluation. Standardised written and clinical skills assessments for breathing and non-breathing baby scenarios were used. Additionally, written surveys were completed during evaluation for feedback on the EENC experience. RESULTS:Fifty-three healthcare workers were included in the evaluation. Median time between initial coaching and evaluation was 21?months (IQR 18-26). Median written score increased from 44% at baseline to 89% post-coaching (p?<?0.001), and was 61% at evaluation (p?<?0.001). Skills assessment score was 20% at baseline and 95% post-coaching in the Breathing Baby scenario (p?<?0.001). In the Non-Breathing Baby scenario, score was 63% at baseline and 86% post-coaching (p?<?0.001). At evaluation, median score in the Breathing Baby scenario was 82% a reduction of 13% from post-coaching (p?<?0.001) and 72% for the Non-Breathing Baby, a reduction of 14% post-coaching (p?<?0.001). Nurse aides had least reduction in evaluation scores of -?2% for the Breathing Baby and midwives -?10% for the Non-Breathing Baby respectively from post-coaching to evaluation. CONCLUSIONS:EENC coaching resulted in immediate improvements in knowledge and skills but declined over time. Healthcare workers who used the skills in regular practice had higher scores. Complementary quality improvement strategies are needed to sustain resuscitation skills following training over time. TRIAL REGISTRATION:Australia New Zealand Trial Registry, Retrospective Registration (12/2/2019), registration number ACTRN12619000201178.

Project description:BackgroundSuccessful reduction of malaria transmission to very low levels has made Isabel Province, Solomon Islands, a target for early elimination by 2014. High malaria transmission in neighbouring provinces and the potential for local asymptomatic infections to cause malaria resurgence highlights the need for sub-national tailoring of surveillance interventions. This study contributes to a situational analysis of malaria in Isabel Province to inform an appropriate surveillance intervention.MethodsA mixed method study was carried out in Isabel Province in late 2009 and early 2010. The quantitative component was a population-based prevalence survey of 8,554 people from 129 villages, which were selected using a spatially stratified sampling approach to achieve uniform geographical coverage of populated areas. Diagnosis was initially based on Giemsa-stained blood slides followed by molecular analysis using polymerase chain reaction (PCR). Local perceptions and practices related to management of fever and treatment-seeking that would impact a surveillance intervention were also explored using qualitative research methods.ResultsApproximately 33% (8,554/26,221) of the population of Isabel Province participated in the survey. Only one subject was found to be infected with Plasmodium falciparum (Pf) (96 parasites/?L) using Giemsa-stained blood films, giving a prevalence of 0.01%. PCR analysis detected a further 13 cases, giving an estimated malaria prevalence of 0.51%. There was a wide geographical distribution of infected subjects. None reported having travelled outside Isabel Province in the previous three months suggesting low-level indigenous malaria transmission. The qualitative findings provide warning signs that the current community vigilance approach to surveillance will not be sufficient to achieve elimination. In addition, fever severity is being used by individuals as an indicator for malaria and a trigger for timely treatment-seeking and case reporting. In light of the finding of a low prevalence of parasitaemia, the current surveillance system may not be able to detect and prevent malaria resurgence.ConclusionAn adaption to the malERA surveillance framework is proposed and recommendations made for a tailored provincial-level surveillance intervention, which will be essential to achieve elimination, and to maintain this status while the rest of the country catches up.

Project description:BACKGROUND:Smoking is the leading cause of preventable death and disease, yet implementation of smoking cessation in inpatient settings is inconsistent. The Technology Inpatient Program for Smokers (TIPS) is an implementation program designed to reach smokers with a mobile health (mHealth) intervention using stakeholder-supported strategies. OBJECTIVE:The purpose of this study was to determine the impact of the TIPS implementation strategies on smoker-level engagement of the mHealth intervention during care transition. METHODS:We examined varying intensities (passive motivational posters only and posters + active nurse-led facilitation) of TIPS strategies on four hospital units located in two sites. Unit-level and smoker-level adoption was monitored during active implementation (30 weeks) and sustainability follow-up (30 weeks). Process measures reflecting the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework, stakeholder reported adaptations of strategies, and formative evaluation data were collected and analyzed. RESULTS:For our smoker-level reach, 103 smokers signed up for the mHealth intervention in-hospital, with minimal decline during sustainability follow-up. While posters + nurse facilitation did not lead to higher reach than posters alone during active implementation (27 vs 30 signed up), it did lead to higher engagement of smokers (85.2% vs 73.3% completion of the full 2-week intervention). TIPS strategy adoption and fidelity varied by unit, including adoption of motivational posters (range: weeks 1 and 5), fidelity of posters (0.4% to 16.2% of posters missing per unit weekly) and internal facilitation of nurse training sessions (average of 2 vs 7.5 by site). Variable maintenance costs of the program totaled US $6.63 (US $683.28/103) per smoker reached. Reported family-member facilitation of mHealth sign-up was an observation of unintended behavior. CONCLUSIONS:TIPS is a feasible and low-cost implementation program that successfully engages smokers in an mHealth intervention and sustains engagement after discharge. Further testing of nurse facilitation and expanding reach to patient family and friends as an implementation strategy is needed.

Project description:BACKGROUND:Improving respectful maternity care (RMC) is a recommended practice during childbirth as a strategy to eliminate the mistreatment of women and improve maternal health. There is limited evidence on the effectiveness of RMC interventions and implementation challenges, especially in low-resource settings. This study describes lessons learned in RMC training and its implementation from the perspectives of service providers' perceptions and experiences. METHODS:Our mixed methods study employed a pre- and post-intervention quantitative survey of training participants to assess their perceptions of RMC and focus group discussions, two months following the intervention, investigated the experiences of implementing RMC within birthing facilities. The intervention was a three-day RMC training offered to 64 service providers from three hospitals in southern Ethiopia. We performed McNemar's test to analyse differences in participants' perceptions of RMC before and after the training. The qualitative data were analysed using hybrid thematic analysis. Integration of the quantitative and qualitative methods was done throughout the design, analysis and reporting of the study. RESULTS:Mistreatment of women during childbirth was widely reported by participants, including witnessing examinations without privacy (39.1%), and use of physical force (21.9%) within the previous 30?days. Additionally, 29.7% of participants reported they had mistreated a woman. The training improved the participants' awareness of the rights of women during childbirth and their perceptions and attitudes about RMC were positively influenced. However, participants believed that the RMC training did not address providers' rights. Structural and systemic issues were the main challenges providers reported when trying to implement RMC in their contexts. CONCLUSION:Training alone is insufficient to improve the provision of RMC unless RMC is addressed through a lens of health systems strengthening that addresses the bottlenecks, including the rights of providers of childbirth care.

Project description:BACKGROUND:Solomon Islands is one of the least developed countries in the world. Recognising that timely detection of outbreaks is needed to enable early and effective response to disease outbreaks, the Solomon Islands government introduced a simple syndromic surveillance system in 2011. We conducted the first evaluation of the system and the first exploration of a national experience within the broader multi-country Pacific Syndromic Surveillance System to determine if it is meeting its objectives and to identify opportunities for improvement. METHODS:We used a multi-method approach involving retrospective data collection and statistical analysis, modelling, qualitative research and observational methods. RESULTS:We found that the system was well accepted, highly relied upon and designed to account for contextual limitations. We found the syndromic algorithm used to identify outbreaks was moderately sensitive, detecting 11.8% (IQR: 6.3-25.0%), 21.3% (IQR: 10.3-36.8%), 27.5% (IQR: 12.8-52.3%) and 40.5% (IQR: 13.5-65.7%) of outbreaks that caused small, moderate, large and very large increases in case presentations to health facilities, respectively. The false alert rate was 10.8% (IQR: 4.8-24.5%). Rural coverage of the system was poor. Limited workforce, surveillance resourcing and other 'upstream' health system factors constrained performance. CONCLUSIONS:The system has made a significant contribution to public health security in Solomon Islands, but remains insufficiently sensitive to detect small-moderate sized outbreaks and hence should not be relied upon as a stand-alone surveillance strategy. Rather, the system should sit within a complementary suite of early warning surveillance activities including event-based, in-patient- and laboratory-based surveillance methods. Future investments need to find a balance between actions to address the technical and systems issues that constrain performance while maintaining simplicity and hence sustainability.

Project description:Background: There is growing evidence demonstrating the benefits of intradialytic cycling. However, there are relatively few centers where this practice has been adopted with no reports from hemodialysis units in rural, remote, and northern locations. Maintaining mobility and quality of life for patients on kidney replacement therapy living in remote northern communities is inhibited by inclement weather and lack of access to resources and infrastructure that support physical activity. The integration of intradialytic cycling during hemodialysis offers patients a form of safe physical activity year-round. Objective: This study focuses on better understanding the feasibility and acceptability of implementing intradialytic cycling in a remote northern geographical context. Design: A feasibility study using a mixed-methods explanatory design was adopted for this study. Setting: The research is conducted in Prince George, British Columbia. Participants: The participants are patients attending a community-based dialysis unit in remote northern British Columbia and health professionals working in the same facility. Methods: Quantitative measures were captured through cycling logbooks and quality of life measure, and qualitative data were obtained through semi-structured interviews and analyzed using thematic analysis. Results: Six (43%) eligible patients used leg ergometers more than once for a median of 2.5 (interquartile range: 1-4) months and 87% of hemodialysis sessions. Participants cycled for a median of 65 (interquartile range: 39-76) minutes per session, with frequent variability noted between participants and different hemodialysis sessions for the same participant. Nine patients completed the European Quality of Life Health Questionnaire prestudy, with 5 (56%) also completing it poststudy. Interviews with 9 patients, 4 nurses, and 1 physiotherapist led to the identification of themes instrumental to implementation: a supportive community dialysis unit, shared responsibility, knowledge of patients/providers, and benefits associated with engagement. Themes that were identified as being key to acceptability in this remote dialysis unit were trust, connection, and engagement through common values. Limitations: Due to dialysis unit size, we had a small number of participants. Conclusions: This study demonstrates the feasibility of implementing best practice in a remote community and provides insight into the elements of context and participation that contribute to acceptability in the implementation of intradialytic cycling.

Dataset Information

Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study.

Publications

Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study.

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