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

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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.

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Most cited references 13

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Are quality improvement collaboratives effective? A systematic review

Susan Wells, Orly Tamir, Jonathon Gray … (2018)

Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.

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Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation

Sozinho Daniel Ndima, Mohsin Sidat, Celso Give … (2015)

Background Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation. Methods Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework. Results Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE’s motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE’s work – factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system. Conclusion The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.

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Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations

Bijal A Balasubramanian, Deborah Cohen, Melinda Davis … (2015)

Background In healthcare change interventions, on-the-ground learning about the implementation process is often lost because of a primary focus on outcome improvements. This paper describes the Learning Evaluation, a methodological approach that blends quality improvement and implementation research methods to study healthcare innovations. Methods Learning Evaluation is an approach to multi-organization assessment. Qualitative and quantitative data are collected to conduct real-time assessment of implementation processes while also assessing changes in context, facilitating quality improvement using run charts and audit and feedback, and generating transportable lessons. Five principles are the foundation of this approach: (1) gather data to describe changes made by healthcare organizations and how changes are implemented; (2) collect process and outcome data relevant to healthcare organizations and to the research team; (3) assess multi-level contextual factors that affect implementation, process, outcome, and transportability; (4) assist healthcare organizations in using data for continuous quality improvement; and (5) operationalize common measurement strategies to generate transportable results. Results Learning Evaluation principles are applied across organizations by the following: (1) establishing a detailed understanding of the baseline implementation plan; (2) identifying target populations and tracking relevant process measures; (3) collecting and analyzing real-time quantitative and qualitative data on important contextual factors; (4) synthesizing data and emerging findings and sharing with stakeholders on an ongoing basis; and (5) harmonizing and fostering learning from process and outcome data. Application to a multi-site program focused on primary care and behavioral health integration shows the feasibility and utility of Learning Evaluation for generating real-time insights into evolving implementation processes. Conclusions Learning Evaluation generates systematic and rigorous cross-organizational findings about implementing healthcare innovations while also enhancing organizational capacity and accelerating translation of findings by facilitating continuous learning within individual sites. Researchers evaluating change initiatives and healthcare organizations implementing improvement initiatives may benefit from a Learning Evaluation approach. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0219-z) contains supplementary material, which is available to authorized users.

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Contributors

Christine Kim: Role: ConceptualizationRole: Data CurationRole: Formal AnalysisRole: Funding AcquisitionRole: InvestigationRole: MethodologyRole: Project AdministrationRole: VisualizationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing

ORCID: https://orcid.org/0000-0001-6211-911X

Ramadhan Kirunda: Role: ConceptualizationRole: Data CurationRole: Formal AnalysisRole: InvestigationRole: MethodologyRole: Project AdministrationRole: SupervisionRole: Writing – Original Draft PreparationRole: Writing – Review & Editing

Frederick Mubiru: Role: Project AdministrationRole: SupervisionRole: Writing – Review & Editing

Nilufar Rakhmanova: Role: ConceptualizationRole: MethodologyRole: Writing – Original Draft PreparationRole: Writing – Review & Editing

Leigh Wynne: Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Project AdministrationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing

Journal

Journal ID (nlm-ta): Gates Open Res

Journal ID (iso-abbrev): Gates Open Res

Journal ID (pmc): Gates Open Res

Title: Gates Open Research

Publisher: F1000 Research Limited (London, UK )

ISSN (Electronic): 2572-4754

Publication date (Electronic): 4 June 2019

Publication date Collection: 2019

Volume: 3

Electronic Location Identifier: 1481

Affiliations

[1 ]Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7411, USA

[2 ]FHI 360, Kitante Close, Kampala, Uganda

[3 ]FHI 360, 825 Connecticut Ave NW, Washington, DC, 20009, USA

[4 ]FHI 360, 359 Blackwell Street #200, Durham, NC, 27701, USA

[1 ]University Research Co., LLC, Kampala, Uganda

[1 ]Department of Public Health Sciences, Karolinska Institutet, Solna, Sweden

Author notes

[a ] christine.kim@ 123456unc.edu

No competing interests were disclosed.

Competing interests: No competing interests were disclosed.

Author information

Christine Kim https://orcid.org/0000-0001-6211-911X

Article

DOI: 10.12688/gatesopenres.12973.1

PMC ID: 6650767

SO-VID: 039b76fc-c4ce-4044-8dab-fe06aa6d494a

License:

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date accepted : 23 May 2019

Funding

Funded by: Boren Fellowship

Funded by: Bill and Melinda Gates Foundation

Award ID: OPP1181398

Funded by: United States Agency for International Development

This work was supported by the Bill and Melinda Gates Foundation [OPP1181398]. We are grateful to the United States Agency for International Development (USAID) and the Boren Fellowship for their financial support to conduct this process evaluation and to USAID for funding the APC project implementation. APC is a cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-12-00047, beginning October 1, 2012. APC is implemented by JSI Research & Training Institute, Inc., in collaboration with FHI 360.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

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Most cited references 13

Are quality improvement collaboratives effective? A systematic review

Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation

Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations

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