Effectiveness of a multi-country implementation-focused network on quality of care: Delivery of interventions and processes for improved maternal, newborn and child health outcomes.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) aims to work through learning, action, leadership and accountability. We aimed to evaluate the effectiveness of QCN in these four areas at the global level and in four QCN countries: Bangladesh, Ethiopia, Malawi and Uganda. This mixed method evaluation comprised 2-4 iterative rounds of data collection between 2019-2022, involving stakeholder interviews, hospital observations, QCN members survey, and document review. Qualitative data was analysed using a coding framework developed from underlying theories on network effectiveness, behaviour change, and QCN proposed theory of change. Survey data capturing respondents' perception of QCN was analysed with descriptive statistics. The QCN global level, led by the WHO secretariat, was effective in bringing together network countries' governments and global actors via providing online and in-person platforms for communication and learning. In-country, various interventions were delivered in 'learning districts', however often separately by different partners in different locations, and pandemic-disrupted. Governance structures for quality of care were set-up, some preceding QCN, and were found to be stronger and better (though often externally) resourced at national than local levels. Awareness of operational plans and network activities differed between countries, was lower at local than national levels, but increased from 2019 to 2022. Engagement with, and value of, QCN was perceived to be higher in Uganda and Bangladesh than in Malawi or Ethiopia. Capacity building efforts were implemented in all countries-yet often dependent on implementing partners and donors. QCN stakeholders agreed 15 core monitoring indicators though data collection was challenging, especially for indicators requiring new or parallel systems. Accountability initiatives remained nascent in 2022. Global and national leadership elements of QCN have been most effective to date, with action, learning and accountability more challenging, partner or donor dependent, remaining to be scaled-up, and pandemic-disrupted.

Influences on policy-formulation, decision-making, organisation and management for maternal, newborn and child health in Bangladesh, Ethiopia, Malawi and Uganda: The roles and legitimacy of a multi-country network.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) is intended to facilitate learning, action, leadership and accountability for improving quality of care in member countries. This requires legitimacy-a network's right to exert power within national contexts. This is reflected, for example, in a government's buy-in and perceived ownership of the work of the network. During 2019-2022 we conducted iterative rounds of stakeholder interviews, observations of meetings, document review, and hospital observations in Bangladesh, Ethiopia, Malawi, Uganda and at the global level. We developed a framework drawing on three models: Tallberg and Zurn which conceptualizes legitimacy of international organisations dependent on their features, the legitimation process and beliefs of audiences; Nasiritousi and Faber, which looks at legitimacy in terms of problem, purpose, procedure, and performance of institutions; Sanderink and Nasiritousi, to characterize networks in terms of political, normative and cognitive interactions. We used thematic analysis to characterize, compare and contrast institutional interactions in a cross-case synthesis to determine salient features. Political and normative interactions were favourable within and between countries and at global level since collective decisions, collaborative efforts, and commitment to QCN goals were observed at all levels. Sharing resources and common principles were not common between network countries, indicating limits of the network. Cognitive interactions-those related to information sharing and transfer of ideas-were more challenging, with the bi-directional transfer, synthesis and harmonization of concepts and methods, being largely absent among and within countries. These may be required for increasing government ownership of QCN work, the embeddedness of the network, and its legitimacy. While we find evidence supporting the legitimacy of QCN from the perspective of country governments, further work and time are required for governments to own and embed the work of QCN in routine care.

Individual interactions in a multi-country implementation-focused quality of care network for maternal, newborn and child health: A social network analysis.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN.

The Epidemiology of Young People's Work and Experiences of Violence in Nine Countries: Evidence from the Violence against Children Surveys.

Globally, 497 million young people (15-24 years) are in the labour force. The current research on work and violence indicates reciprocal links across the life course. This study draws on data from 35,723 young people aged 13-24 years in the Violence Against Children Surveys (VACS) in nine countries to describe the epidemiology of work in order to explore associations between (1) current work and violence and (2) childhood violence and work in a hazardous site in young adulthood. The prevalence of past-year work among 13-24-year-olds was highest in Malawi: 82.4% among young men and 79.7% among young women. In most countries, young women were more likely to be working in family or domestic dwellings (range: 23.5-60.6%) compared to men (range: 8.0-39.0%), while men were more likely to be working on a farm. Work in a hazardous site was higher among young men compared to women in every country. Among children aged 13-17 years, we found significant positive associations between past-year work and violence among girls in three countries (aORs between 2.14 and 3.07) and boys in five countries (aORs 1.52 to 3.06). Among young people aged 18-24 years, we found significant positive associations among young women in five countries (aORs 1.46 to 2.61) and among young men in one country (aOR 2.62). Associations between childhood violence and past-year work in a hazardous site among 18-24-year-olds were significant in one country among girls and in three countries among boys. Continued efforts are needed to prevent hazardous work, improve work environments, and integrate violence prevention efforts into workplaces.

Workplace Violence Against Adolescents, Uganda, 2014-2019.

Objectives. To describe the prevalence of and risk factors for workplace violence among Ugandan adolescents. Methods. The analysis focused on adolescents recruited at primary schools who participated in the endline survey of a trial in 2014 (at ages 11-14 years) and were followed up in 2018-2019 (at ages 17-19 years). The analysis was restricted to those engaged in past-year paid work (n = 1406). We estimated the prevalence of past-year workplace violence and used mixed-effects multivariable logistic regression to explore associations with characteristics measured in early adolescence, current life circumstances, and work-related factors. Methods. The analysis focused on adolescents recruited at primary schools who participated in a 2014 survey and were followed up in 2018-2019. The analysis was restricted to those engaged in past-year paid work (n = 1406). We estimated the prevalence of past-year workplace violence and used mixed-effects multivariable logistic regression to explore associations with characteristics measured in early adolescence, current life circumstances, and work-related factors. Results. Overall, 40% (95% confidence interval [CI] = 37%, 43%) of adolescents in paid work experienced past-year workplace violence; odds were doubled among female domestic workers (vs retail/trade workers; adjusted odds ratio [AOR] = 2.07; 95% CI = 1.28, 3.35). Experiences measured in early adolescence, including eating less than 3 meals the previous day, experiencing severe physical violence (male adolescents: AOR = 1.48; 95% CI = 1.11, 1.98; female adolescents: AOR = 1.69; 95% CI = 1.13, 2.53) and bullying, and having poor mental health (male adolescents: AOR = 2.32 95% CI = 1.37, 3.92; female adolescents: AOR = 2.27; 95% CI = 1.05, 4.89), were associated with increased odds of workplace violence. Current life circumstances (fewer household assets, more moves, functional difficulties, poorer mental health) were also associated with workplace violence. Conclusions. Interventions are needed to address the high prevalence of workplace violence across all sectors, with female domestic workers particularly vulnerable. Early prevention of violence and poor mental health may be promising. (Am J Public Health. 2022;112(11):1651-1661. https://doi.org/10.2105/AJPH.2022.306983).

Paper: violence, abuse and exploitation among trafficked women and girls: a mixed-methods study in Nigeria and Uganda.

BACKGROUND: Africa is the global region where modern-slavery is most prevalent, especially among women and girls. Despite the severe health consequences of human trafficking, evidence on the risks and experiences of trafficked adolescents and young women is scarce for the region. This paper addresses this gap by exploring the intersections between violence, migration and exploitation among girls and young women identified as trafficking survivors in Nigeria and Uganda. METHODS: We conducted secondary analysis of the largest routine dataset on human trafficking survivors. We used descriptive statistics to report the experiences of female survivors younger than 25 years-old from Nigeria and Uganda. We also conducted 16 semi-structured interviews with adolescents identified as trafficked in both countries. We used thematic analysis to explore participants' perceptions and experiences before, during and after the trafficking situation. RESULTS: Young female survivors of human trafficking in Nigeria and Uganda are exposed to a range of experiences of violence before migration, during transit and at destination. The qualitative data revealed that children and adolescents migrated to escape family poverty, violence and neglect. They had very low levels of education and most had their studies interrupted before migrating. Family members and close social contacts were the most common intermediaries for their migration. During transit, sexual violence and hunger were common, especially among Nigerians. Participants in both the quantitative and qualitative studies reported high levels of violence, deception, coercion, withheld wages and poor working conditions at destination. The adolescents interviewed in the qualitative study reported severe mental suffering, including suicide attempts. Only one reported the prosecution of perpetrators. CONCLUSIONS: Our findings suggest that interventions to prevent or mitigate the negative impact of adverse childhood experiences can contribute to preventing the trafficking of adolescents in Nigeria and Uganda. These interventions include social protection mechanisms, universal access to education, social service referrals and education of parents and carers. Importantly, effective prevention also needs to address the systemic conditions that makes trafficking of female adolescents invisible, profitable and inconsequential for perpetrators.