Exploring community participation in project design: application of the community conversation approach to improve maternal and newborn health in Zambia.

BACKGROUND: The United Nations Development Programme (UNDP) has adopted an approach entitled Community Conversation (CC) to improve community engagement in addressing health challenges. CCs are based on Paulo Freire's transformative communication approach, in which communities pose problems and critically examine their everyday life experiences through discussion. We adopted this approach to engage communities in maternal and newborn health discussions in three rural districts of Zambia, with the aim of developing community-generated interventions. METHODS: Sixty (60) CCs were held in three target districts, covering a total of 20 health facilities. Communities were purposively selected in each district to capture a range of rural and peri-urban areas at varying distances from health facilities. Conversations were held four times in each community between May and September 2014. All conversations were digitally recorded and later transcribed. NVivo version 10 was used for data analysis. RESULTS AND DISCUSSION: The major barriers to accessing maternal health services included geography, limited infrastructure, lack of knowledge, shortage of human resources and essential commodities, and insufficient involvement of male partners. From the demand side, a lack of information and misconceptions, and, from the supply side, inadequately trained health workers with poor attitudes, negatively affected access to maternal health services in target districts either directly or indirectly. At least 17 of 20 communities suggested solutions to these challenges, including targeted community sensitisation on the importance of safe motherhood, family planning and prevention of teenage pregnancy. Community members and key stakeholders committed time and resources to address these challenges with minimal external support. CONCLUSION: We successfully applied the CC approach to explore maternal health challenges in three rural districts of Zambia. CCs functioned as an advocacy platform to facilitate direct engagement with key decision makers within the community and to align priorities while incorporating community views. There was a general lack of knowledge about safe motherhood and family planning in all three districts. However, other problems were unique to health facilities, demonstrating the need for tailored interventions.

Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa.

BACKGROUND: Despite global efforts to increase health workforce capacity through training and guidelines, challenges remain in bridging the gap between knowledge and quality clinical practice and addressing health system deficiencies preventing health workers from providing high quality care. In many developing countries, supervision activities focus on data collection, auditing and report completion rather than catalyzing learning and supporting system quality improvement. To address this gap, mentorship and coaching interventions were implemented in projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) as components of health systems strengthening (HSS) strategies funded through the Doris Duke Charitable Foundation's African Health Initiative. We report on lessons learned from a cross-country evaluation. METHODS: The evaluation was designed based on a conceptual model derived from the project-specific interventions. Semi-structured interviews were administered to key informants to capture data in six categories: 1) mentorship and coaching goals, 2) selection and training of mentors and coaches, 3) integration with the existing systems, 4) monitoring and evaluation, 5) reported outcomes, and 6) challenges and successes. A review of project-published articles and technical reports from the individual projects supplemented interview information. RESULTS: Although there was heterogeneity in the approaches to mentorship and coaching and targeted areas of the country projects, all led to improvements in core health system areas, including quality of clinical care, data-driven decision making, leadership and accountability, and staff satisfaction. Adaptation of approaches to reflect local context encouraged their adoption and improved their effectiveness and sustainability. CONCLUSION: We found that incorporating mentorship and coaching activities into HSS strategies was associated with improvements in quality of care and health systems, and mentorship and coaching represents an important component of HSS activities designed to improve not just coverage, but even further effective coverage, in achieving Universal Health Care.

Hypertension management in rural primary care facilities in Zambia: a mixed methods study.

BACKGROUND: Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening, monitoring, treatment and control of high blood pressure. METHODS: Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content. RESULTS: From January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89.1% overall (range: 70.1-100%), but decreased to 62.1% (range: 0-100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were <10% and did not improve with time. In in-depth interviews, antihypertensive medication shortages were common, with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts. Principal challenges in hypertension management included 1) equipment and personnel shortages, 2) provider belief that multiple visits were needed before official management, 3) medication stock-outs, leading to improper prescriptions and 4) poor patient visit attendance. CONCLUSIONS: Our findings suggest that numerous barriers stand in the way of hypertension diagnosis and management in Zambian primary health facilities. Future work should focus on performance indicator development and validation in low resource contexts, to facilitate regular and systematic data review to improve patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier NCT01942278 . Date of Registration: September 2013.