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      Implementation of a community-based intervention in the most rural and remote districts of Zambia: a process evaluation of safe motherhood action groups

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          Abstract

          Background

          A community-based intervention known as Safe Motherhood Action Groups (SMAGs) was implemented to increase coverage of maternal and neonatal health (MNH) services among the poorest and most remote populations in Zambia. While the outcome evaluation demonstrated statistically significant improvement in the MNH indicators, targets for key indicators were not achieved, and reasons for this shortfall were not known. This study was aimed at understanding why the targeted key indicators for MNH services were not achieved.

          Methods

          A process evaluation, in accordance with the Medical Research Council (MRC) framework, was conducted in two selected rural districts of Zambia using qualitative approaches. Focus group discussions were conducted with SMAGs, volunteer community health workers, and mothers and in-depth interviews with healthcare providers. Content analysis was done.

          Results

          We found that SMAGs implemented much of the intervention as was intended, particularly in the area of women’s education and referral to health facilities for skilled MNH services. The SMAGs went beyond their prescribed roles to assist women with household chores and personal problems and used their own resources to enhance the success of the intervention. Deficiencies in the intervention were reported and included poor ongoing support, inadequate supplies and lack of effective transportation such as bicycles needed for the SMAGs to facilitate their work. Factors external to the intervention, such as inadequacy of health services and skilled healthcare providers in facilities where SMAGs referred mothers and poor geographical access, may have led SMAGs to engage in the unintended role of conducting deliveries, thus compromising the outcome of the intervention.

          Conclusion

          We found evidence suggesting that although SMAGs continue to play pivotal roles in contribution towards accelerated coverage of MNH services among hard-to-reach populations, they are unable to meet some of the critical sets of MNH service-targeted indicators. The complexities of the implementation mechanisms coupled with the presence of setting specific socio-cultural and geographical contextual factors could partially explain this failure. This suggests a need for innovating existing implementation strategies so as to help SMAGs and any other community health system champions to effectively respond to MNH needs of most-at-risk women and promote universal health coverage targeting hard-to-reach groups.

          Electronic supplementary material

          The online version of this article (10.1186/s13012-018-0766-1) contains supplementary material, which is available to authorized users.

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          Most cited references30

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          Achieving child survival goals: potential contribution of community health workers.

          There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.
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            Outcome effectiveness of community health workers: an integrative literature review.

            Community health workers (CHWs) are promoted as a mechanism to increase community involvement in health promotion efforts, despite little consensus about the role and its effectiveness. This article reviews the databased literature on CHW effectiveness, which indicates preliminary support for CHWs in increasing access to care, particularly in underserved populations. There are a smaller number of studies documenting outcomes in the areas of increased health knowledge, improved health status outcomes, and behavioral changes, with inconclusive results. Although CHWs show some promise as an intervention, the role can be doomed by overly high expectations, lack of a clear focus, and lack of documentation. Further research is required with an emphasis on stronger study design, documentation of CHW activities, and carefully defined target populations.
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              Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study

              Background Despite the policy change stopping traditional birth attendants (TBAs) from conducting deliveries at home and encouraging all women to give birth at the clinic under skilled care, many women still give birth at home and TBAs are essential providers of obstetric care in rural Zambia. The main reasons for pregnant women’s preference for TBAs are not well understood. This qualitative study aimed to identify reasons motivating women to giving birth at home and seek the help of TBAs. This knowledge is important for the design of public health interventions focusing on promoting facility-based skilled birth attendance in Zambia. Methods We conducted ten focus group discussions (n = 100) with women of reproductive age (15–45 years) in five health centre catchment areas with the lowest institutional delivery rates in the district. In addition, a total of 30 in-depth interviews were conducted comprising 5 TBAs, 4 headmen, 4 husbands, 4 mothers, 4 neighbourhood health committee (NHC) members, 4 community health workers (CHWs) and 5 nurses. Perspectives on TBAs, the decision-making process regarding home delivery and use of TBAs, and reasons for preference of TBAs and their services were explored. Results Our findings show that women’s lack of decision- making autonomy regarding child birth, dependence on the husband and other family members for the final decision, and various physical and socioeconomic barriers including long distances, lack of money for transport and the requirement to bring baby clothes and food while staying at the clinic, prevented them from delivering at a clinic. In addition, socio-cultural norms regarding childbirth, negative attitude towards the quality of services provided at the clinic, made most women deliver at home. Moreover, most women had a positive attitude towards TBAs and perceived them to be respectful, skilled, friendly, trustworthy, and available when they needed them. Conclusion Our findings suggest a need to empower women with decision-making skills regarding childbirth and to lower barriers that prevent them from going to the health facility in time. There is also need to improve the quality of existing facility-based delivery services and to strengthen linkages between TBAs and the formal health system.
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                Author and article information

                Contributors
                choolwe2003@yahoo.com
                ccmichelo@yahoo.com
                moshabela@ukzn.ac.za
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1748-5908
                31 May 2018
                31 May 2018
                2018
                : 13
                : 74
                Affiliations
                [1 ]ISNI 0000 0001 0723 4123, GRID grid.16463.36, School of Nursing and Public Health, , University of KwaZulu-Natal, ; Durban, South Africa
                [2 ]ISNI 0000 0000 8914 5257, GRID grid.12984.36, School of Public Health, Department of Epidemiology and Biostatistics, , University of Zambia, ; Lusaka, Zambia
                [3 ]ISNI 0000 0000 8914 5257, GRID grid.12984.36, Strategic Centre for Health Systems Metrics and Evaluations (SCHEME), School of Public Health, , University of Zambia, ; Lusaka, Zambia
                [4 ]GRID grid.488675.0, Africa Health Research Institute, ; KwaZulu Natal, South Africa
                Article
                766
                10.1186/s13012-018-0766-1
                5984469
                29855324
                9b4187d9-96c3-4f53-941e-cf98cdc8f87b
                © The Author(s). 2018

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 3 January 2018
                : 21 May 2018
                Funding
                Funded by: African Union Commission PhD Scholarship
                Funded by: African Doctoral Dissertation Research Fellowship by African population and Health Research Center in partnership with the International Development Research Centre (IDRC)
                Categories
                Research
                Custom metadata
                © The Author(s) 2018

                Medicine
                access to healthcare,process evaluation,maternal health,neonatal health,remote and rural areas,lay health workers,zambia

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