Process evaluation of the Yéego! Program to increase healthy eating and gardening among American Indian elementary school children.

BACKGROUND: American Indian children are at increased risk for obesity and diabetes. School-based health promotion interventions are one approach to promoting healthy behaviors to reduce this risk, yet few studies have described their implementation and fidelity. We conducted a qualitative process evaluation of the Yéego! Healthy Eating and Gardening Program, a school-based intervention to promote healthy eating among Navajo elementary school children. The intervention included a yearlong integrated curriculum, as well as the construction and maintenance of a school-based garden. METHODS: Our process evaluation included fidelity checklists completed by program staff and qualitative interviews with program staff and classroom teachers after the intervention was implemented. We used content analysis to identify themes. RESULTS: We identified several themes related to evidence of delivery adherence, program satisfaction, and lessons learned about delivery. Intervention staff followed similar procedures to prepare for and deliver lessons, but timing, teaching styles, and school-level factors also impacted overall implementation fidelity. Teachers and students had positive perceptions of the program, especially lessons that were highly visual, experiential, and connected to Navajo culture and the surrounding community. Teachers and program staff identified ways to enhance the usability of the curriculum by narrowing the scope, relating content to student experiences, and aligning content with school curriculum standards. CONCLUSIONS: The program was implemented with moderately high fidelity across contexts. We identified areas where modifications could improve engagement, acceptability, efficacy, and sustainability of the program. Our results have implications for the evaluation and dissemination of school-based health interventions to promote healthy eating among children, especially in American Indian communities.

Costs of implementing and sustaining enhanced collaborative care programs involving community partners.

BACKGROUND: Collaborative care is an evidence-based program for treating depression in primary care. We sought to expand this model by recruiting clinics interested in incorporating community partners (i.e., community-based organizations (CBO) and/or family members) in the care team. Seven sites implemented evidence-based collaborative care programs with community partners while collecting information on costs of implementing and sustaining programs. METHODS: Sites retrospectively collected data on planning and implementation costs with technical assistance from study researchers. Sites also prospectively collected cost of care activities over a 1-month period once the program was implemented to determine resources needed to sustain programs. Personnel salary costs were adjusted, adding 30% for benefits and 30% for administrative overhead. RESULTS: The programs implemented varied considerably in staffing, involvement of care partners, and allocation of costs. Total planning and implementation costs varied from $39,280 to $60,575. The largest implementation cost category involved workflow development and ranged from $16,325 to $31,375 with the highest costs in this category attributed to the most successful implementation among clinic-CBO programs. Following implementation, cost per patient over the 1-month period ranged from $154 to $544. Ongoing strategic decision-making and administrative costs, which were included in cost of care, ranged from $284 to $2328 for the month. CONCLUSIONS: Sites implemented collaborative care through differing partnerships, staffing, and related costs. Costs to implement and sustain programs developed in partnership are often not collected but are crucial to understanding financial aspects of developing sustainable partnerships. Assessing such costs is feasible and can inform future partnership efforts.

Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe.

PROBLEM: In Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths. APPROACH: We established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital. LOCAL SETTING: Maternal mortality in Zimbabwe has increased from 555 to 960 per 100,000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff. RELEVANT CHANGES: Following an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014. LESSONS LEARNT: Introducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.