Search

Absrtact Objective To understand perspectives and experiences related to participation in a quality improvement collaborative (QIC) to improve person-centered care (PCC) for maternal health and family planning (FP) in Kenya. Design and setting Semi-structured qualitative interviews were conducted with members of the QIC in four public health facilities in Kenya. Participants Clinical and nonclinical public health facility staff who had participated in the QIC were purposively sampled to participate in the semi-structured interviews. Intervention A QIC was implemented across four public health facilities in Nairobi and Kiambu Counties in Kenya to improve PCC experiences for women seeking maternity or FP services. Main outcome measure Semi-structured interviews with participants of the QIC to understand perspectives and experiences associated with sensitization to and implementation of PCC behaviors in maternity and FP services. Results Respondents reported that sensitization to PCC principles resulted in multiple perceived benefits for staff and patients alike, including improved interactions with patients and clients, deeper awareness of patient and client preferences, and improved interpersonal skills and greater job satisfaction. Respondents also highlighted system-level challenges that impeded their ability to consistently provide high-quality PCC to women, namely staff shortages and frequent turnover, high patient volumes and lack of space in their respective health facilities. Conclusion Respondents were easily able to articulate perceived benefits derived from participation in this QIC, although they were equally able to identify challenges that hindered their ability to consistently provide high-quality PCC to women seeking maternity or FP services. more...

Background: Person-centered quality for family planning has been gaining increased attention, yet few interventions have focused on this,or measured associations between PCFP and family planning outcomes (uptake, continuation, etc.). In India, the first point of contact for family planning is often the community health care worker, in this case, Accredited Social Health Activists (ASHAs). Methods: In this study, we evaluate a training on person-centered family planning as an add-on to a training on family planning provision for urban ASHAs in Varanasi, India in 2019 using mixed methods. We first validate a scale to measure person-centered family planningin a community health worker population, and find it to be valid. Higher person-centered family planningscores are associated with family planning uptake. Results: Comparing women who saw intervention compared to control ASHAs, we find that the intervention had no impact on overall person-centered family planningscores. Women in the intervention arm were more likely to report that their ASHA had a strong preference about what method they choose, suggesting that the training increased provider pressure. However, qualitative interviews with ASHAs suggest that they value person-centered care for their interactions and absorbed the messages from the intervention.Conclusions: More research is needed on how to intervene to change behaviors related to person-centered family planning.This study received IRB approval from the University of California, San Francisco (IRB # 15-25950) and was retrospectively registered at clinicaltrials.gov (NCT04206527) on 20 December 2019.https://clinicaltrials.gov/ct2/show/NCT04206527?term=NCT04206527&draw=2&rank=1 more...

BackgroundPoor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and require significant external input, making replication and scale difficult. This study compared the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch. MethodsWe used a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome. ResultsBoth Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed. ConclusionsThis study demonstrated that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time. Trial RegistrationQI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019. link to the registration:https://clinicaltrials.gov/ct2/show/NCT04208867?term=NCT04208867&draw=2&rank=1QI Phase 2 – NCT04208841. Retrospectively registered. December 23, 2019. link to the registration:https://clinicaltrials.gov/ct2/show/NCT04208841?term=NCT04208841&draw=2&rank=1CONTRIBUTIONS TO THE LITERATURE 98 words· Medical practioners’ treatment of patients are influenced by institutional norms and difficult to change. · Team-based initiatives which actively engage staff have been effective in wealthy countries but are not common in middle-income settings, and have not been applied to person-centered aspects of care.· We found that team-based quality improvement efforts were effective in India at changing patient experience. Once change-practices were identified, these practices were introduced to new facilities with low-intesity support and proved equally effective at improving care.· These findings add to the limited evidence on team-based quality improvement, and provide evidence of effective scaleable implementation opportunities. more...

Conducting clinical trials in resource-poor settings may contribute to local capacity building. We describe the perspectives of local research personnel regarding the impact of collaborating in a clinical trial in rural Ghana. Forty-six Ghanaian research personnel were eligible to complete an anonymous survey, and 35 (76%) participated. Of the 35 respondents, 32 (91%) agreed that future patients will benefit because the hospital was part of the study. All 35 respondents reported a personal benefit derived from study involvement, most commonly citing skills or knowledge gained. Of the 35 individuals, 21 reported one or more burdens, most commonly citing nonspecific research responsibilities. Our data support the hypothesis that participation in clinical trials can contribute to capacity building in district hospitals in a lower middle-income country. more...

Ghanaian children (2176) aged, A respiratory pathogen was identified in 59% of Ghanaian children who presented with acute respiratory distress. Rhinovirus and/or enterovirus was identified most commonly. Respiratory syncytial virus and metapneumovirus were detected more frequently in the rainy season than in the dry season. more...

Background: Quality of care for family planning, especially person-centered care, is important from a health and human-rights standpoint. Few interventions have aimed to improve person-centered family planning (PCFP) in low and middle-income countries. In this study, we tested the impact of a quality improvement (QI) intervention in Kenya on aspects of PCFP included in a validated measure of PCFP and on the overall PCFP scale. Methods: We conducted QI cycles in three facilities providing family planning in Nairobi and Kiambu Counties, Kenya, with three facilities serving as controls. Cross-sectional baseline data was collected from 478 women receiving family planning in 2016 and end line data was collected from 640 in 2017-18. We analysed the impact of the QI intervention on PCFP using difference-in-difference models. Results: We found no impact of the QI intervention on either PCFP or the overall PCFP scale. Conclusions: We take away key lessons learned from the null findings of the intervention that are important for future interventions. Lessons learned include the need to be flexible in light of external factors that prolonged the study and probably led to burnout; and simplifying measurement and procedures. more...

Summary Background In low-income and middle-income countries, invasive mechanical ventilation is often not available for children at risk of death from respiratory failure. We aimed to determine if continuous positive airway pressure (CPAP), a form of non-invasive ventilation, decreases all-cause mortality in children with undifferentiated respiratory distress in Ghana. Methods This open-label, cluster, crossover trial was done in two Ghanaian non-tertiary hospitals where invasive mechanical ventilation is not routinely available. Eligible participants were children aged from 1 month to 5 years with a respiratory rate of more than 50 breaths per min in children 1–12 months old, or more than 40 breaths per min in children older than 12 months, and use of accessory muscles or nasal flaring. CPAP machines were allocated to one hospital during each study block, while the other hospital served as the control site. The initial intervention site was randomly chosen using a coin toss. 5 cm of water pressure was delivered via CPAP nasal prongs. The primary outcome measure was all-cause mortality rate at 2 weeks after enrolment in patients for whom data were available after 2 weeks. We also did post-hoc regression analysis and subgroup analysis of children by malaria status, oxygen saturation, and age. This study is registered with ClinicalTrials.gov, number NCT01839474. Findings Between Jan 20, 2014, and Dec 5, 2015, 2200 children were enrolled: 1025 at the intervention site and 1175 at the control site. Final analysis included 1021 patients in the CPAP group and 1160 patients in the control group. 2 weeks after enrolment, 26 (3%) of 1021 patients in the CPAP group, and 44 (4%) of 1160 patients in the control group, had died (relative risk [RR] of mortality 0·67, 95% CI 0·42–1·08; p=0·11). In children younger than 1 year, all-cause mortality was ten (3%) of 374 patients in the CPAP group, and 24 (7%) of 359 patients in the control group (RR 0·40, 0·19–0·82; p=0·01). After adjustment for study site, time, and clinically important variables, the odds ratio for 2-week mortality in the CPAP group versus the control group was 0·4 in children aged up to 6 months, 0·5 for children aged 12 months, 0·7 for children aged 24 months, and 1·0 for those aged 36 months. 28 patients (3%) in the CPAP group and 24 patients (2%) in the control group had CPAP-related adverse events, such as vomiting, aspiration, and nasal, skin, or eye trauma. No serious adverse events were observed. Interpretation In the unadjusted analysis the use of CPAP did not decrease all-cause 2-week mortality in children 1 month to 5 years of age with undifferentiated respiratory distress. After adjustment for study site, time, and clinically important variables, 2-week mortality in the CPAP group versus the control group was significantly decreased in children 1 year of age and younger. CPAP is safe and improves respiratory rate in a non-tertiary setting in a lower-middle-income country. Funding General Electric Foundation. more...

A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya-from their perspective-to better understand their actual and perceived responsibilities in maternity care.In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach.Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients.Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.RESUMEN Contexto: Un creciente conjunto de evidencia indica que miembros del personal no clínico de las instituciones de salud proporcionan apoyos que trascienden sus roles tradicionales, particularmente en países de bajos y medianos ingresos. Es importante examinar el rol del personal de limpieza de las instituciones de salud en Kenia–desde su perspectiva—para comprender mejor sus responsabilidades reales y percibidas en cuanto a la atención materna. Métodos: Se condujeron entrevistas personales en profundidad utilizando una guía semiestructurada con 14 miembros del personal de limpieza que trabajaban en tres instituciones de salud pública en los condados de Nairobi y Kiambu, Kenia, en agosto y septiembre de 2016. Los resultados fueron codificados y categorizados mediante un enfoque de análisis de contenido temático. Resultados: El personal de limpieza reportó que realizaba una variedad de servicios además de sus responsabilidades típicas de mantenimiento, que incluyeron la provisión de apoyo emocional, informativo e instrumental a las pacientes de maternidad. Describieron un sentimiento de falta de respeto cuando las pacientes estaban desaseadas o experimentaban sangrado; sin embargo, tales ejemplos revelaron la necesidad de que el personal de limpieza comprendiera mejor los procesos de trabajo de parto y parto. El personal de limpieza también indicó su deseo de recibir capacitación en habilidades interpersonales para mejorar su interacción con las mujeres. Conclusión: La participación directa del personal de limpieza en la atención a pacientes de maternidad es un síntoma alarmante de sobrecarga de las instituciones de salud, de personal insuficiente y de capacitación inadecuada. Este grupo de personal de atención a la salud, clave pero ignorado, merece apoyo apropiado y se necesita mayor investigación para comprender y mitigar los defectos del sistema de salud y mejorar la calidad de la prestación de servicios de salud materna.RÉSUMÉ Contexte: La documentation et les données indiquent de plus en plus que le travail du personnel non clinique des structures de soins de santé s'étend au-delà du rôle qu'on attendrait ordinairement de lui, en particulier dans les pays à revenu faible ou intermédiaire. Il importe d'examiner — de leur point de vue — le rôle des effectifs de nettoyage des structures sanitaires du Kenya si l'on veut mieux comprendre leurs responsabilités réelles et perçues dans les soins de maternité. Méthodes: Des entretiens en personne approfondis, suivant un guide semi-structuré, ont été menés avec 14 membres du personnel de nettoyage de trois structures sanitaires de l'État dans les comtés de Nairobi et de Kiambu (Kenya), en août et septembre 2016. Les résultats ont été codés et catégorisés selon une approche d'analyse de contenu thématique. Résultats: Le personnel de nettoyage interrogé a déclaré effectuer des services allant au-delà des responsabilités d'entretien types, y compris l'apport d'un soutien affectif, informatif et matériel aux patientes des services de maternité. Il estimait subir un manque de respect lorsque les patientes présentaient une allure peu soignée ou saignaient. Ces exemples révèlent cependant la nécessité pour le personnel de nettoyage de mieux comprendre les processus du travail et de l'accouchement. Le personnel interrogé a également exprimé un désir de formation en matière de compétences interpersonnelles, en vue d'une meilleure interaction avec les femmes. Conclusion: La participation directe du personnel de nettoyage aux soins de maternité des patientes représente un symptôme alarmant de structures sanitaires surchargées, d'effectifs insuffisants et de formation inadéquate. Cette catégorie d'effectifs sanitaires, essentielle mais généralement négligée, mérite un soutien approprié. Une recherche approfondie doit être entreprise pour comprendre et combler les lacunes du système de santé et pour améliorer la qualité de prestation des soins de maternité. more...

Doula care meets each of the triple aims of the Affordable Care Act: improving health outcomes for all, improving the experience of care, and lowering costs by reducing non-beneficial and unwanted medical interventions. Cost is the greatest barrier to use of doula support. Reimbursement for doula services by private insurance, Medicaid, and Medicaid managed care organizations would significantly increase access to doulas. Widespread availability of doula care could significantly reduce cesarean rates, and increased access to community-based doula programs could reduce entrenched health disparities. more...