respectful maternity care implementation research in tanzania: the staha project gwu miliken school...
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Respectful Maternity Care implementation research in Tanzania: The Staha Project
GWU Miliken School of Public Health
June 24, 2014
AIM:REDUCE D&A
medicine and supplies stockouts
community doesn’t know their rights
health workers don’t know their rights
distrust between providers and
clients
health worker burnout &
demotivationlack of safe channels
to report D&A
organizational culture in the health system
provocation by relatives
modeling of D&A behaviours in training
unfair processe
s in the health
systemweak
accountabilityPOWER
DYNAMICS
discrepancy between policy promises and reality
lack of recognition for good performance
infrastructure weaknesses
workforce shortages
stress of maternity assignment
ethics
Pre-intervention qualitative data: Patient-provider interactions• Misunderstandings about what is the health workers’ fault
and what is due to system constraints • Community distrust health workers, think that they steal
medicines and sell in their own pharmacies• Health providers distrust community, think that they don’t
understand what actually happened/are ignorant• Good interactions exist outside the work environment (as
neighbors or at social events), but changes at facility• Nurses are typically blamed• Neither patients nor providers feel that they know their rights
Values driven process:
Mutuality of respect
Patients
Respectful Health System Environment
Providers RESPECT
Participatory planningPreliminary
results, identification
of root causes,
brainstorm solutions
Stakeholders across levels:• National• Regional• District • Facility• Community
Propose and review potential solutions
Community members
Village and ward leaders
Health workers in
the maternity
District and facility
management
Represent-atives
from local groups
Community members
Health workers in
the maternity
Staha Change Process• Client Service Charter
– Adapt the national charter in a participatory process at district and health facility level to elaborate the value of mutual respect
• Facility-based quality improvement– maternity teams address issues related to mutual respect and
devise ways to implement and measure change
• Community and health system management actions– Communities implement and monitor activities to support providers
and ensure accountability– District leaders and managers change practices to support an
environment of respect and attention for providers and patients
District and facility
management policy and practice changes
Facility-based QI
process to change
environment/ practice
Community-driven
actions to support and
monitor system
District-level
adaptation of charter
Facility- level
adaptation of charter
Norms and
standards of mutual respect
Increased mutual respect
Consensus building on norms and standards
Multi-level activation of mutual respect norms Improved outcomes
Increased facility-based
deliveryReduced D&A
during childbirth
STAHA CHANGE PROCESS
Implementation research:data collection methodsCharter QI processQualitative interviews/FGDs Maternity exit surveyDrafting meeting minutes Provider weekly surveyParticipant observation Weekly observationCharter feedback forms Collective efficacy surveyDissemination/activity monitoring forms*
QI team weekly meeting minutesQualitative interviews/FGDs
Implementation research strategy
• Based on:– Damschroder et al’s Consolidated Framework for Advancing
Implementation Science (CFIR)– Carroll et al’s Framework for Implementation Fidelity
• Overall goal of studying and uncovering the process of the implementation under key domains:– Moderators of change– Support mechanisms– Context and inner/outer settings– Fidelity
Intervention components
Client Service Charter• National charter developed in 2005, never adapted
at district levels• Korogwe is the first district to adapt charter to
reflect local needs and concerns• District charter developed first, followed by facility-
specific charters• Mechanism to open dialogue between different
levels of district health system and communities
Steps in local charter adaptationAt district & facility levels:• Select charter committee• Review MoHSW/existing charter• Develop new draft of charter• Solicit feedback from multiple stakeholders
through comment forms & community meetings• Integrate comments in charter• Seek approval by District Council• Disseminate, implement & monitor• Make revisions as needed
Frequent Comments on Draft• More transparency of fees
and services• Services should be
provided in a timely manner• Make providers’ rights more
specific• Facilities should be a
corruption-free environment • Use respectful language
when speaking to patients
Key messages in the charter• Mutuality of respect• Patient rights & responsibilities• Provider rights & responsibilities• Standards of service, including relationships• Standards of ethical conduct• Accountability, feedback and complaint
mechanisms• Equality and respect for all• Ongoing maintenance of charter
Dissemination and Activation
• Materials developed to support dissemination– Printed copies of charters– Summaries of key provider and patient rights and
responsibilities– Posters
• Meetings with key leaders at district, health facility and community levels– Training on dissemination of charter – Plans and commitments for charter activation
Quality Improvement Process
• Views disrespect and abuse as a systemic problem rather than an individual or behavioral problem
• Applies a clinical quality improvement framework to an interpersonal quality of care issue (adapts Institute of Healthcare Improvement framework)
Intervention launch at Magunga Hospital, Korogwe District• 2-day workshop to introduce QI to the maternity ward and
key personnel from RCH, theatre, and pharmacy• Staff identified drivers of D&A and proposed specific
interventions for change• 6 people chosen by their peers as the QI team:
– 1 doctor from the maternity ward– 2 nurses from the maternity ward– 1 pharmacist– 1 nurse from RCH– 1 nurse from theatre
• The regional MOH QI specialist and the deputy medical officer in charge at the hospital supervised the team
Quality Improvement Interventions
• Move admission and discharge to a private room• Obtain/use curtains in the delivery room and
screens in the maternity for privacy• Pharmacy creates a stock out list each week to post
in the maternity ward• Recognize providers with tea, certificates, etc.• Peer-to-peer learning with Bombo Hospital QI Team
QI Intervention: Implementation research• Self-reported exit survey of all postpartum women on
quality of care and satisfaction with interaction with providers
Provider knowledgeLanguage useProvider communicationProvider responsiveness Overall quality of care
RespectPrivacyAvailability of drugs and suppliesWard cleanliness
Patient surveys: analysis
• N = 1720, 43 weeks of data from August 2013-April 2014 (ongoing)
• Two weeks of baseline data collection• Data divided into pre-post intervention at week 19
– All interventions implemented by week 15– At week 19, providers started to use a checklist per
patient to ensure that interventions were followed
Patient surveys: logistic regression analysis• Outcome categorized as excellent vs. other
categories• Main predictor: pre/post 19 weeks• Controlled for age and clustered on date
Patient surveys: results to questions (%)
Excellent Good Fair Poor
Overall quality of care 70.01 27.24 2.58 0.18Respect 70.30 27.83 1.76 0.12Privacy 68.13 28.66 3.22 0.06Language use 65.33 31.55 3.06 0.06Provider communication 66.86 31.07 1.83 0.24Availability of supplies 70.35 26.13 2.94 0.59Provider knowledge 73.72 24.10 2.06 0.12Ward cleanliness 65.44 30.99 3.04 0.53
Patient surveys: results to questions by time period (%)
< 19 weeks ≥ 19 weeks
Excellent Good Fair Poor Excellent Good Fair Poor
Overall quality of care
63.34 32.69 3.69 0.27 75.00 23.16 1.74 0.10Respect 61.39 35.61 2.73 0.27 77.00 21.97 1.03 0.10Privacy 62.79 32.28 4.79 0.14 72.13 25.92 1.95 0.00Language use 58.07 37.24 4.55 0.14 70.73 27.33 1.94 0.00Provider communication 60.64 36.58 2.23 0.56 71.44 27.02 1.54 0.00Availability of supplies 62.17 32.87 4.26 0.69 76.43 21.11 1.95 0.51Provider knowledge 70.66 27.27 1.79 0.28 76.00 21.74 2.26 0.00Ward cleanliness
58.45 37.60 3.27 0.68 70.70 26.02 2.87 0.41
Overall quality of care.4
.5.6
.7.8
% r
atin
g a
s e
xce
llent
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Respect.4
.5.6
.7.8
.9%
ra
ting
as e
xcelle
nt
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Privacy.5
.6.7
.8.9
% r
ating
as e
xcelle
nt
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Provider language.4
.5.6
.7.8
.9%
ra
ting
as e
xcelle
nt
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Provider communication.4
.5.6
.7.8
% r
ating
as e
xcelle
nt
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Availability of supplies
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
.4.5
.6.7
.8.9
% r
ating
as e
xcelle
nt
0 10 20 30 40Weeks
Provider knowledge
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
.5.6
.7.8
.9%
ra
ting
as e
xcelle
nt
0 10 20 30 40Weeks
Ward cleanliness.4
.5.6
.7.8
.9%
ra
ting
as e
xcelle
nt
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Other events in maternity ward: example – overall quality of care
.4.5
.6.7
.8%
ra
ting
as
exce
llent
0 10 20 30 40Weeks
Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions
Week 18: nursing students start
Weeks 27-29: staff shortage
Week 24: nurse changes
Patient surveys: regression results
Outcome Odds Ratio
95% CI
Overall quality of care 1.59*** 1.20-2.13
Respect 1.95*** 1.47-2.58
Privacy 1.40* 1.08-1.82
Language use 1.61*** 1.24-2.09
Provider communication 1.45** 1.12-1.87
Availability of supplies 1.93*** 1.45-2.56
Provider knowledge 1.16 0.87-1.54
Ward cleanliness 1.45** 1.10-1.91
P-value: *<0.05, **<0.01, ***<0.001
Challenges to implementation • Interventions that require funds or approval by hospital
management can take longer to implement• Maternity ward staff who did not attend the QI training were
less able to explain the process and its importance• Documentation/monitoring of interventions can be difficult
due to poor record-keeping at the maternity ward • Some women express concern when using moveable
screens in the maternity ward that being covered during examination implies serious illness
Limitations of findings
• Preliminary results not adjusted for time trends• Trend could be due to something other than
intervention (ex: availability of supplies)• Positivity effect: women could be rating everything
as positive overall• Women have changed over time?• No comparison group
Implications for future Staha research• End line survey to see if intervention is having an
effect on D&A
Thank you
Moderators of change: key questions• How have key stakeholders contributed to the
implementation/intervention? • How did participants of the intervention react to and
accept the intervention? • How has the perception of disrespect and abuse
changed over time?• What is the role of the health providers’ collective
efficacy in facilitating change?• How have the power dynamics between patients and
providers changed?
Moderators of change: data components• Charter process:
– Personal narration by charter facilitator– In-depth interviews with key stakeholders– Participant observations
• QI process:– In-depth interviews with key stakeholders– FGDs with health providers– Patient exit survey– Provider survey– Provider collective efficacy survey
Support mechanisms
• Key question:– To what extent did the Staha team itself affect the
outcome of the intervention? For example, what occurred/may not have occurred without the support and facilitation of the implementers/researchers?
• Data component:– Project documents– Qualitative interviews
Fidelity• Key questions:
– To what extent is the intervention being implemented as intended?
– What were the challenges to implementation? What elements of the intervention were adapted during the implementation in order to react to the realities on the ground?
• Data components:– Project documents, meeting minutes– Qualitative interviews with key stakeholders and participants– Observations
Context: inner/outer settings
• Key question:– How do the social, economic, structural, and political
factors of the intervention district, including of the targeted intervention community and of the health facilities, affect the implementation and the intervention outcome?
• Data components:– Qualitative interviews with key stakeholders– Landscape scanning
Charter Process: Preliminary lessons• Charter committee representation from district government and health
system and community• D&A in childbirth as lens onto broader quality issues – touches on
many encounters with the health system• Building consensus
– Allow space for airing contentious issues– Gradual consensus building from disparate perspectives
• System insiders open to new possibilities; recognize value of community perspectives
• Community representatives made aware of structural/capacity limitations; recognize their own power to make change
• Local government leaders start recognize their role in ensuring quality of health services for their populations