"Quality teaches you how to use water. It doesn't provide a water pump": a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program.

BACKGROUND: Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives' varied impacts. METHODS: To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. RESULTS: The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. CONCLUSIONS: The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.

Newborn care: A qualitative study of inter-cultural variations and similarities among two ethnic groups in Northeastern Nigeria.

Background: Neonatal mortality remains unacceptably high in most sub-Saharan and Asian communities, where cultural practices and poor antenatal care are common. Newborn care practices play a key role in preventing neonatal deaths. Aims: This study aimed to examine similarities and variations in newborn care between two major ethnic groups in northeast Nigeria. Subjects And Methods: Qualitative methods involving narratives, observations, focus group discussions, and in-depth interviews were used to collect data from recent mothers (ten per ethnic group) and grandmothers from the Babur/Bura and Kanuri ethnic groups in Borno State, Northeast Nigeria. A snowballing sampling technique was used to select the participants within four communities/villages (two for each ethnic group). Results: Babies were bathed within 30 to 45 minutes after delivery by mothers in both groups, except in case of ill health of the child and/or mother. Various substances were applied to the cord even though hygienic cord-cutting practice was reported. With the exception of early bathing, good thermal care practices were observed in both groups. Both groups applied emollients on the skin of the babies, but Bura preferred the use of shea butter to oils and lotion. Various substances were applied to other parts of the body of the baby, such as the fontanelle (Mahogany oil), anus (Neem oil and Mahogany oil), and circumcision wound (engine oil) more so among the Bura than the Kanuri. None of the substances were deemed to be harmful. Conclusion: Similarities and variations in newborn care exist between the two ethnic groups. There is a need for health education and promotion to encourage and facilitate positive behavioral change from old traditional practices to healthy newborn care practices among the Babur/Bura and Kanuri ethnic groups.

Roles and responsibilities in newborn care in four African sites.

OBJECTIVES: To explore roles and responsibilities in newborn care in the intra- and postpartum period in Nigeria, Tanzania and Ethiopia. METHODS: Qualitative data were collected using in-depth interviews with mothers, grandmothers, fathers, health workers and birth attendants and were analysed through content and framework analyses. RESULTS: We found that birth attendants were the main decision-makers and care takers in the intrapartum period. Birth attendants varied across sites and included female relatives (Ethiopia and Nigeria), traditional birth attendants (Tanzania and Nigeria), spiritual birth attendants (Nigeria) and health workers (Tanzania and Nigeria). In the early newborn period, when the mother is deemed to be resting, female family members assumed this role. The mothers themselves only took full responsibility for newborn care after a few days or weeks. The early newborn period was protracted for first-time mothers, who were perceived as needing training on caring for the baby. Clear gender roles were described, with newborn care being considered a woman's domain. Fathers had little physical contact with the newborn, but played an important role in financing newborn care, and were considered the ultimate decision-maker in the family. CONCLUSION: Interventions should move beyond a focus on the mother-child dyad, to include other carers who perform and decide on newborn care practices. Given this power dynamic, interventions that involve men have the potential to result in behaviour change.

'Children awaken by playing': a qualitative exploration of caregivers' norms, beliefs and practices related to young children's learning and early childhood development in rural Burkina Faso.

INTRODUCTION: Evidence suggests that responsive caregiving and early learning activities positively impact developmental outcomes, with positive effects throughout the life course. Early childhood development interventions should align with local values, beliefs and resources but there has been little research of caregiver beliefs and perspectives on development and learning, especially in sub-Saharan Africa. This qualitative study explored norms, beliefs, practices and aspirations around child development of caregivers of young children in rural Burkina Faso. METHODS: We conducted 32 in-depth interviews with mothers and fathers of young children and 24 focus group discussions with mothers, fathers and grandmothers, which included trying behaviours and reporting on experiences. The research informed the development of Scaling Up Nurturing Care, a Radio Intervention to Stimulate Early Childhood Development (SUNRISE), an early child development radio intervention. RESULTS: Caregivers described a process of 'awakening', through which children become aware of themselves and the world around them.Perceptions of the timing of awakening varied, but the ability to learn was thought to increase as children became older and more awake. Consequently, talking and playing with babies and younger children were perceived to have little developmental impact. Caregivers said children's interactions with them, alongside God-given intelligence, was believed to impact later behaviour and development. Caregivers felt their role in helping their children achieve later in life was to pay for education, save money, provide advice and be good role models. Interaction and learning activities were not specifically mentioned. Caregivers who trialled interaction and learning activities reported positive experiences for themselves and their child, but interactions were often caregiver led and directive and play was often physical. Key barriers to carrying out the behaviours were poverty and a lack of time. CONCLUSIONS: Exploring early childhood beliefs and practices can reveal important sociocultural beliefs which, if incorporated into programme planning and implementation, could help achieve more impactful, acceptable and equitable programmes. TRIAL REGISTRATION NUMBER: NCT05335395.

Newborn care: the effect of a traditional illness, asram, in Ghana.

AIMS: To explore the role of a traditional illness of the newborn, asram, in care-seeking in rural Ghana. METHODS: Data are from formative research into newborn care which included collecting qualitative data from 14 villages in Brong Ahafo region of Ghana through 25 birth narratives, 30 in-depth interviews and two focus groups with recently delivered/pregnant women, 20 in-depth interviews and six focus groups with birth attendants/grandmothers, 12 in-depth interviews and two focus groups with husbands, and six in-depth interviews with asram healers. RESULTS: The study confirmed that asram is characterised by symptoms which include green/black veins, a big head and the newborn growing lean. However, a complex classification of 14 types of asram covering a wide array of symptoms was identified. Asram was perceived as a common illness which cannot be treated at health facilities and to which many danger signs in the newborn are attributed, and thus it affects care-seeking. Asram treatment includes frequent cold herbal baths and air-drying; however, oral treatments and preventive bathing are also used. Any modification of asram treatment was reported to require the sanction of a healer. CONCLUSION: Understanding traditional illnesses as a potential barrier to newborn care-seeking is essential for designing care-seeking interventions. An asram diagnosis can prevent sick newborns being taken to health facilities and traditional treatment exposes them to the risk of hypothermia.

Erratum to "Maternal, neonatal and child health interventions and services: moving from knowledge of what works to systems that deliver" [International Health 2 (2010) 87-98].

The Publisher regrets that an error occurred in the name of the 6th listed co-author for this paper. B. Matthias was listed in the original paper instead of M. Borchert; the correct listing can be seen above.

Informed consent in Ghana: what do participants really understand?

OBJECTIVES: To explore how subjects in a placebo-controlled vitamin A supplementation trial among Ghanaian women aged 15-45 years perceive the trial and whether they know that not all trial capsules are the same, and to identify factors associated with this knowledge. METHODS: 60 semistructured interviews and 12 focus groups were conducted to explore subjects' perceptions of the trial. Steps were taken to address areas of low comprehension, including retraining fieldworkers. 1971 trial subjects were randomly selected for a survey measuring their knowledge that not all trial capsules are the same. The subjects' fieldworkers were also interviewed about their characteristics and trial knowledge. Factors associated with knowledge were explored using multi-level modeling. RESULTS: Although subjects knew they were taking part in research, most thought they were receiving an active and beneficial medication. Variables associated with knowledge were education and district of residence. Radio broadcasts benefited those with some schooling. Fieldworkers' characteristics were not associated with subjects' knowledge. CONCLUSIONS: Research and debate on new or improved consent procedures are urgently required, particularly for subjects with little education.

Early initiation of breast-feeding in Ghana: barriers and facilitators.

To explore why women in Ghana initiate breast-feeding early or late, who gives advice about initiation and what foods or fluids are given to babies when breast-feeding initiation is late. Qualitative data were collected through 52 semistructured interviews with recent mothers, 8 focus group discussions with women of child-bearing age and 13 semistructured interviews with health workers, policy makers and implementers. The major reasons for delaying initiation of breast-feeding were the perception of a lack of breast milk, performing postbirth activities such as bathing, perception that the mother and the baby need rest after birth and the baby not crying for milk. Facilitating factors for early initiation included delivery in a health facility, where the staff encouraged early breast-feeding, and the belief in some ethnic groups that putting the baby to the breast encourages the milk. Policy makers tended to focus on exclusive breast-feeding rather than early initiation. Most activities for the promotion of early initiation of breast-feeding were focused on health facilities with very few community activities. It is important to raise awareness about early initiation of breast-feeding in communities and in the policy arena. Interventions should focus on addressing barriers to early initiation and should include a community component.

How did formative research inform the development of a home-based neonatal care intervention in rural Ghana?

Formative research is often used to inform intervention design, but the design process is rarely reported. This study describes how an integrated home visit intervention for newborns in Ghana was designed. As a first step in the design process, the known intervention parameters were listed, information required to refine the intervention was then identified and a formative research strategy designed. The strategy included synthesizing available data, collecting data on newborn care practices in homes and facilities, on barriers and facilitators to adopting desired behaviors and on practical issues such as whom to include in the intervention. The data were used to develop an intervention plan through workshops with national and international stakeholders and experts. The intervention plan was operationalized by district level committees. This included developing work plans, a creative brief for the materials and completing a community volunteer inventory. The intervention was then piloted and the intervention materials were finalized. The design process took over a year and was iterative. Throughout the process, literature was reviewed to identify the best practice. The intervention focuses on birth preparedness, using treated bednets in pregnancy, early and exclusive breastfeeding, thermal care, special care for small babies and prompt care seeking for newborns with danger signs. The need for a problem-solving approach was identified to help ensure behavior change. A subset of behaviors were already being performed adequately, or were the focus of other interventions, but were important to reinforce in the visits. These include attending antenatal care and care seeking for danger signs in pregnancy. On the basis of the intervention content, the timing of newborn deaths and the acceptability of visits, two antenatal and three visits in the first week of life (days 1, 3 and 7) were planned. Several household members were identified to include in the visits as they were involved in newborn care or they made financial decisions. Birth attendants and health workers were often the locus of control for immediate newborn care, and sensitization activities were designed to improve their practices and to help ensure that families received consistent messages. An existing cadre of community volunteers was identified to deliver the intervention-these volunteers were already trusted and accepted by the community, already visited pregnant women at home and had the time and commitment to deliver the intervention. A supervision and remuneration system was developed through discussions with the volunteers and at the planning workshops. The need for community entry activities was identified to garner community support for the intervention, to encourage self-identification of pregnant and delivered women and to motivate the volunteer through community recognition. Formative research is an essential step in helping to ensure the development of an effective, appropriate and sustainable intervention.

Protein cross-match test for the diagnosis and prevention of reactions after the transfusion of blood and cryoprecipitate.

The examination by means of counterimmunoelectrophoresis for protein incompatibility of the serum of 62 patients who developed an allergic or pyretic post-transfusion reaction revealed incompatibility in 23 cases (37.2%). It was due to the presence of antibodies in 8 recipients (34.8%) and in 15 blood donors (65.2%). The incidence was significantly higher than in a control group of transfused patients who did not develop a reaction. In this group protein incompatibility was found in only 14.7%, 80% of which was due to antibodies in the recipient. In 13 (56.5%) of the patients with reactions agglutinating, cytotoxic or complement fixing antibodies against cellular antigens or IgG were found in addition to protein incompatibility. In 10 cases (43.5%) protein incompatibility was the only explanation for the clinical symptoms. When, in the treatment of multiply transfused haemophiliacs who regularly developed adverse reactions, donors for the preparation of cryoprecipitate were selected by means of the described technique, the almost obligatory reactions were prevented.