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  • 1.
    Baker, Ulrike
    et al.
    Univ Malawi, Dept Family Med, Coll Med, Blantyre, Malawi;Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy Res, Stockholm, Sweden;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Family Med, Huddinge, Sweden.
    Petro, Arafumin
    Ifakara Hlth Inst, Hlth Syst Impact Evaluat & Policy HSIEP, Dar Es Salaam, Tanzania.
    Marchant, Tanya
    London Sch Hyg & Trop Med, Dept Dis Control, London, England.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy Res, Stockholm, Sweden;Makerere Sch Publ Hlth, Kampala, Uganda;UNICEF, Hlth Sect, Programme Div, New York, NY USA.
    Manzi, Fatuma
    Ifakara Hlth Inst, Hlth Syst Impact Evaluat & Policy HSIEP, Dar Es Salaam, Tanzania.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). UCL, Inst Global Hlth, London, England.
    Hanson, Claudia
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy Res, Stockholm, Sweden;London Sch Hyg & Trop Med, Dept Dis Control, London, England.
    Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 12, article id e0209092Article in journal (Refereed)
    Abstract [en]

    Background: Quality Improvement (OI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect.

    Materials and methods: A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARI HS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes.

    Results: Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention's comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge.

    Conclusion: Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.

  • 2.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Namusoko, Sarah
    School of Public Health, Makerere University College of Health Sciences, New Mulago Hospital Complex, Uganda.
    Waiswa, Peter
    Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Sweden.
    Wallin, Lars
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Sweden.
    Knowledge translation in Uganda: a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework2012In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 7, no 1, p. 117-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting.

    METHODS:

    This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data.

    RESULTS:

    The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT.

    CONCLUSIONS:

    In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.

  • 3.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Skeen, Sarah
    Duc, Duong M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Blandon, Elmer Zelaya
    Estabrooks, Carole
    Gustavsson, Petter
    Hoa, Dinh Thi Phuong
    Kallestal, Carina
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nga, Nguyen Thu
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pervin, Jesmin
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Rahman, Anisur
    Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Squires, Janet E.
    Tomlinson, Mark
    Waiswa, Peter
    Wallin, Lars
    Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings2015In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 10, article id 120Article in journal (Refereed)
    Abstract [en]

    Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

  • 4.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Tomlinson, M.
    Squires, J.
    Duong, Duc
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Hoa, D. P.
    Källestål, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pervin, J.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nga, Nguyen Thu
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Rahman, A.
    Waiswa, P.
    Zelaya, E.
    Estabrooks, C.
    Wallin, L.
    The context assessment for community health tool: investigating why what works where2013In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 18, no SI, p. 203-204Article in journal (Other academic)
  • 5.
    Bergström, Anna
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ugarte Guevara, William J.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Eustachio Colombo, Patricia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Knowledge about Sexual and Reproductive Health among School Enrolled Adolescents in Tololar, Nicaragua, A Cross-Sectional Study2018In: Journal of Public Health International, Vol. 1, no 2, p. 27-38Article in journal (Refereed)
    Abstract [en]

    Background: Nicaragua has the highest prevalence of teenage pregnancies in Latin America. Knowledge regarding sexual and reproductive health plays an integral part in sexual behavior. The objective was to assess school going adolescents' knowledge about sexual and reproductive health and possible factors affecting it in the semi-rural community of Tololar, Nicaragua.

    Methods: A cross-sectional study with a self-administered questionnaire on tablets was used for data collection. All 253 registered students at the school present at the time of fieldwork who gave written informed consent were deemed eligible for the study. A total of 225 participants in the ages of 11-19 years were included. Simple linear regression and multiple linear regression were performed analyzing the outcome knowledge. A p-value <0.05 was considered significant.

    Results: The general knowledge about sexual and reproductive health was moderate; however, knowledge gaps were found such as prevailing myths and poor knowledge regarding human immunodeficiency virus (hiv) transmission and contraceptive methods. Being female and single were significant negative determinants of knowledge (p-value < 0.01) and knowledge increased significantly with age (p-value < 0.05). School teachers, websites, social networks, and TV were the most frequently chosen sources of information on the topic.

    Conclusions: Increased education on sexual and reproductive health with new interventions particularly for young females is recommended. Using IT-based materials as a complement may be an effective way to reach out to adolescents.

  • 6.
    Blacklock, Claire
    et al.
    Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom.
    Gonçalves Bradley, Daniela C
    Nuffield Department of Population Health, University of Oxford, United Kingdom.
    Mickan, Sharon
    Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom.
    Willcox, Merlin
    Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom.
    Roberts, Nia
    Nuffield Department of Population Health and Bodleian Healthcare Library, Knowledge Centre, University of Oxford, United Kingdom.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Mant, David
    Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom.
    Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa: Review of Randomised Clinical Trials2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 1, article id e0145206Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Africa bears 24% of the global burden of disease but has only 3% of the world's health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.

    METHODS AND FINDINGS: A systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions' components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.

    CONCLUSIONS: Interventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.

  • 7.
    Duc, Duong M.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Hanoi Sch Publ Hlth, Fac Social Sci Behav & Hlth Educ, 138 Giang Vo St, Hanoi, Vietnam.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). UCL, Inst Global Hlth, London, England..
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Ha, Bui Thi Thu
    Faculty of Social Science - Behaviours and Health Education, Hanoi School of Public Health, Hanoi, Vietnam.
    Wallin, Lars
    Dalarna Univ, Sch Educ Hlth & Social Studies, Falun, Sweden.;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Stockholm, Sweden..
    Response process and test-retest reliability of the Context Assessment for Community Health tool in Vietnam2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 31572Article in journal (Refereed)
    Abstract [en]

    Background: The recently developed Context Assessment for Community Health (COACH) tool aims to measure aspects of the local healthcare context perceived to influence knowledge translation in low-and middle-income countries. The tool measures eight dimensions (organizational resources, community engagement, monitoring services for action, sources of knowledge, commitment to work, work culture, leadership, and informal payment) through 49 items. Objective: The study aimed to explore the understanding and stability of the COACH tool among health providers in Vietnam. Designs: To investigate the response process, think-aloud interviews were undertaken with five community health workers, six nurses and midwives, and five physicians. Identified problems were classified according to Conrad and Blair's taxonomy and grouped according to an estimation of the magnitude of the problem's effect on the response data. Further, the stability of the tool was examined using a test-retest survey among 77 respondents. The reliability was analyzed for items (intraclass correlation coefficient (ICC) and percent agreement) and dimensions (ICC and Bland-Altman plots). Results: In general, the think-aloud interviews revealed that the COACH tool was perceived as clear, well organized, and easy to answer. Most items were understood as intended. However, seven prominent problems in the items were identified and the content of three dimensions was perceived to be of a sensitive nature. In the test-retest survey, two-thirds of the items and seven of eight dimensions were found to have an ICC agreement ranging from moderate to substantial (0.5-0.7), demonstrating that the instrument has an acceptable level of stability. Conclusions: This study provides evidence that the Vietnamese translation of the COACH tool is generally perceived to be clear and easy to understand and has acceptable stability. There is, however, a need to rephrase and add generic examples to clarify some items and to further review items with low ICC.

  • 8.
    Duc, Duong M.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Hanoi University of Public Health, Vietnam.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Wallin, Lars
    School of Education, Health and Social Studies, Dalarna University, Sweden.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Cummings, Greta
    Faculty of Nursing, University of Alberta, Canada.
    Nga, Nguyen Thu
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Bui, Ha
    Hanoi University of Public Health, Vietnam.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Measuring local healthcare context for knowledge translation in primary and secondary levels of care in northern Vietnam: A cross-sectional studyManuscript (preprint) (Other academic)
    Abstract [en]

    Background

    The influence of context in shaping the effectiveness of knowledge translation (KT) is widely recognized. The Context Assessment for Community Health (COACH) tool aims to assess contextual aspects that are of importance for KT in healthcare in low- and middle-income settings. This study used the COACH tool to describe healthcare context as perceived by health workers in primary and secondary levels of care in a northern province in Vietnam and to further evaluate the internal structure of the COACH tool.

    Methods

    This cross-sectional study administered the COACH tool to 677 eligible health workers in primary and secondary levels of care. The relationships between individual background variables and COACH dimensions were analysed using binary logistic regression. Further, internal construct validity was calculated by a first-order independent cluster model confirmatory factor analysis (CFA).

    Results

    Overall, the healthcare context was perceived as supportive for KT. Gender, age, and geographic location showed significant relationships to one of the COACH dimensions. Male health workers rated their Commitment to work as lower than female health workers (OR=0.39, 95% CI: 0.20–0.78). There were, however, only minor differences in  scores for the dimensions of context, at each health facility as well as between health facilities. The CFA asserted an acceptable internal structure of the COACH tool.

    Conclusions

    The survey enhanced the understanding of how aspects of the healthcare context for KT are perceived by health workers at primary and secondary levels of care in a province in Vietnam. There was an overall positive perception of the work context with only minor variability, reflecting a ‘receptive to change’ context for KT. This should, however, be interpreted with caution due to the risk of social desirability response bias. The findings on the acceptable internal structure of the COACH tool supports its further use as a valid instrument. 

  • 9.
    Duong, Duc M.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wallin, Lars
    Bui, Ha T. T.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Eldh, Ann Catrine
    Exploring the influence of context in a community-based facilitation intervention focusing on neonatal health and survival in Vietnam: a qualitative study2015In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 814Article in journal (Refereed)
    Abstract [en]

    Background: In the Neonatal health - Knowledge into Practice (NeoKIP) trial in Vietnam, local stakeholder groups, supported by trained laywomen acting as facilitators, promoted knowledge translation (KT) resulting in decreased neonatal mortality. In general, as well as in the community-based NeoKIP trial, there is a need to further understand how context influences KT interventions in low- and middle-income countries (LMICs). Thus, the objective of this study was to explore the influence of context on the facilitation process in the NeoKIP intervention. Methods: A secondary content analysis was performed on 16 Focus Group Discussions with facilitators and participants of the stakeholder groups, applying an inductive approach to the content on context through naive understanding and structured analysis. Results: The three main-categories of context found to influence the facilitation process in the NeoKIP intervention were: (1) Support and collaboration of local authorities and other communal stakeholders; (2) Incentives to, and motivation of, participants; and (3) Low health care coverage and utilization. In particular, the role of local authorities in a KT intervention was recognized as important. Also, while project participants expected financial incentives, non-financial benefits such as individual learning were considered to balance the lack of reimbursement in the NeoKIP intervention. Further, project participants recognized the need to acknowledge the needs of disadvantaged groups. Conclusions: This study provides insight for further understanding of the influence of contextual aspects to improve effects of a KT intervention in Vietnam. We suggest that future KT interventions should apply strategies to improve local authorities' engagement, to identify and communicate non-financial incentives, and to make disadvantaged groups a priority. Further studies to evaluate the contextual aspects in KT interventions in LMICs are also needed.

  • 10.
    Eriksson, Leif
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Institute for Global Health, London, United Kingdom.
    Hoa, Dinh Thi Phuong
    Hanoi School of Public Health, Hanoi, Vietnam.
    Nga, Nguyen Thu
    Research Institute for Child Health, Hanoi, Vietnam.
    Eldh, Ann Catrine
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Högskolan Dalarna.
    Sustainability of knowledge implementation in a low- and middle- income context: Experiences from a facilitation project in Vietnam targeting maternal and neonatal health2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 8, article id e0182626Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In a previous trial in Vietnam, a facilitation strategy to secure evidence-based practice in primary care resulted in reduced neonatal mortality over a period of three years. While little is known as to what ensures sustainability in the implementation of community-based strategies, the aim of this study was to investigate factors promoting or hindering implementation, and sustainability of knowledge implementation strategies, by means of the former Neonatal Knowledge Into Practice (NeoKIP) trial.

    METHODS: In 2014 we targeted all levels in the Vietnamese healthcare system: six individual interviews with representatives at national, provincial and district levels, and six focus group discussions with representatives at the commune level. The interviews were transcribed verbatim, translated to English, and analysed using inductive and deductive thematic analysis.

    RESULTS: To achieve successful implementation and sustained effect of community-based knowledge implementation strategies, engagement of leaders and key stakeholders at all levels of the healthcare system is vital-prior to, during and after a project. Implementation and sustainability require thorough needs assessment, tailoring of the intervention, and consideration of how to attain and manage funds. The NeoKIP trial was characterised by a high degree of engagement at the primary healthcare system level. Further, three years post trial, maternal and neonatal care was still high on the agenda for healthcare workers and leaders, even though primary aspects such as stakeholder engagement at all levels, and funding had been incomplete or lacking.

    CONCLUSIONS: The current study illustrates factors to support successful implementation and sustain effects of community-based strategies in projects in low- and middle-income settings; some but not all factors were represented during the post-NeoKIP era. Most importantly, trials in this and similar contexts require deliberate management throughout and beyond the project lifetime, and engagement of key stakeholders, in order to promote and sustain knowledge implementation.

  • 11.
    Eriksson, Leif
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Nga, Nguyen T
    Research Institute for Child Health, Hanoi, Vietnam.
    Hoa, Dinh T Phuong
    Hanoi University of Public Health, Vietnam.
    Duc, Duong M
    Hanoi University of Public Health, Vietnam.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Wallin, Lars
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Huy, Tran Q
    Department of Medical Services Administration, Ministry of Health, Nursing office, Hanoi, Vietnam.
    Thuy, Nguyen T
    Vietnam-Sweden Uong Bi General Hospital, Uong Bi, Vietnam.
    Do, Tran Thanh
    National Institute of Nutrition (NIN), Ministry of Health, Hanoi, Vietnam.
    Lien, Pham T L
    Research Institute for Child Health, Hanoi, Vietnam.
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. London School of Hygiene & Tropical Medicine, London, UK.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Secular trend, seasonality and effects of a community-based intervention on neonatal mortality: follow-up of a cluster-randomised trial in Quang Ninh province, Vietnam2018In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 72, no 9, p. 776-782Article in journal (Refereed)
    Abstract [en]

    Background: Little is know about whether the effects of community engagement interventions for child survival in low-income and middle-income settings are sustained. Seasonal variation and secular trend may blur the data. Neonatal mortality was reduced in a cluster-randomised trial in Vietnam where laywomen facilitated groups composed of local stakeholders employing a problem-solving approach for 3 years. In this analysis, we aim at disentangling the secular trend, the seasonal variation and the effect of the intervention on neonatal mortality during and after the trial.

    Methods: In Quang Ninh province, 44 communes were allocated to intervention and 46 to control. Births and neonatal deaths were assessed in a baseline survey in 2005, monitored during the trial in 2008–2011 and followed up by a survey in 2014. Time series analyses were performed on monthly neonatal mortality data.

    Results: There were 30 187 live births and 480 neonatal deaths. The intervention reduced the neonatal mortality from 19.1 to 11.6 per 1000 live births. The reduction was sustained 3 years after the trial. The control areas reached a similar level at the time of follow-up. Time series decomposition analysis revealed a downward trend in the intervention areas during the trial that was not found in the control areas. Neonatal mortality peaked in the hot and wet summers.

    Conclusions: A community engagement intervention resulted in a lower neonatal mortality rate that was sustained but not further reduced after the end of the trial. When decomposing time series of neonatal mortality, a clear downward trend was demonstrated in intervention but not in control areas.

    Trial registration number: ISRCTN44599712, Post-results.

  • 12.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Chaulagain, Dipak
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Lifeline Nepal, Kathmandu, Nepal.
    Brunell, Olivia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Gurung, Abhishek
    Lifeline Nepal, Kathmandu, Nepal.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Grönqvist, Erik
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Edin, Per-Anders
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Economics.
    Le Grange, Claire
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Lamichhane, Bikash
    Department of Health Services, Ministry of Health, Nepal.
    Shrestha, Parashuram
    Department of Health Services, Ministry of Health, Nepal.
    Pokharel, Amrit
    Department of Health Services, Ministry of Health, Nepal.
    Pun, Asha
    Health Section, UNICEF, UN House, Lalitpur, Nepal.
    Singh, Chahana
    Health Section, UNICEF, UN House, Lalitpur, Nepal .
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial2017In: BMJ global health, Vol. 2, no 3, article id e000497Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Nepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health system structures. The intervention builds on previous research on the implementation of Helping Babies Breathe-quality improvement cycle in a tertiary healthcare setting in Nepal. The objective of this study is to evaluate the effect of this scaled-up intervention on perinatal health outcomes.

    METHODS/DESIGN: Cluster-randomised controlled trial using a stepped wedged design with 3 months delay between wedges will be conducted in 12 public hospitals with a total annual delivery rate of 60 000. Each wedge will consist of 3 hospitals. Impact will be evaluated on intrapartum-related mortality (primary outcome), overall neonatal mortality and morbidity and health worker's performance on neonatal care (secondary outcomes). A process evaluation and a cost-effectiveness analysis will be performed to understand the functionality of the intervention and to further guide health system investments will also be performed.

    DISCUSSION: In contexts where resources are limited, there is a need to find scalable and sustainable implementation strategies for improved care delivery. The proposed study will add to the scarce evidence base on how to scale up interventions within existing health systems. If successful, the NePeriQIP model can provide a replicable solution in similar settings where support and investment from the health system is poor, and national governments have made a global pledge to reduce perinatal mortality.

    TRIAL REGISTRATION NUMBER: ISRCTN30829654.

  • 13.
    Lawn, Joy E
    et al.
    Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK.
    Blencowe, Hannah
    Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK.
    Waiswa, Peter
    Amouzou, Agbessi
    Mathers, Colin
    Hogan, Dan
    Flenady, Vicki
    Frøen, J Frederik
    Qureshi, Zeshan U
    Calderwood, Claire
    Shiekh, Suhail
    Jassir, Fiorella Bianchi
    You, Danzhen
    McClure, Elizabeth M
    Mathai, Matthews
    Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
    Cousens, Simon
    Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK.
    Musafili, Aimable (Contributor)
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Stillbirths: rates, risk factors, and acceleration towards 2030.2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10018, p. 587-603Article in journal (Refereed)
    Abstract [en]

    An estimated 2·6 million third trimester stillbirths occurred in 2015 (uncertainty range 2·4-3·0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas affected by conflict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1·3 million (uncertainty range 1·2-1·6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7·4% of stillbirths. Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8·0% and syphilis 7·7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6·7%). Prolonged pregnancies contribute to 14·0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth.

  • 14.
    Leufvén, Mia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Vitrakoti, Ravi
    Foundation for Maternal and Child Health, Maternity Hospital Road, Thapathali, Kathmandu, Nepal.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Dimensions of Learning Organizations Questionnaire (DLOQ) in a low-resource health care setting in Nepal2015In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 13, no 1, p. 6-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Knowledge-based organizations, such as health care systems, need to be adaptive to change and able to facilitate uptake of new evidence. To be able to assess organizational capability to learn is therefore an important part of health systems strengthening. The aim of the present study is to assess context using the Dimensions of the Learning Organization Questionnaire (DLOQ) in a low-resource health setting in Nepal.

    METHODS:

    DLOQ was translated and administered to 230 employees at all levels of the hospital. Data was analyzed using non-parametric tests.

    RESULTS:

    The DLOQ was able to detect variations across employee's perceptions of the organizational context. Nurses scored significantly lower than doctors on the dimension "Empowerment" while doctors scored lower than nurses on "Strategic leadership". These results suggest that the hospital's organization carries attributes of a centralized, hierarchical structure that might hinder a progress towards a learning organization.

    CONCLUSIONS:

    This study demonstrates that, despite the designing and developing of the DLOQ in the USA and its main utilization in company settings, it can be used and applied in hospital settings in low-income countries. The application of DLOQ provides valuable insights and understanding when designing and evaluating efforts for healthcare improvement.

  • 15.
    Mocumbi, Sibone
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Univ Eduardo Mondlane, Fac Med, Maputo, Mozambique.
    Boene, H.
    Manhica Hlth Res Ctr CISM, Manhica, Mozambique.
    Munguambe, K.
    Univ Eduardo Mondlane, Fac Med, Maputo, Mozambique; Manhica Hlth Res Ctr CISM, Manhica, Mozambique.
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden..
    Hanson, C.
    Karolinska Inst, Dept Publ Hlth, Stockholm, Sweden.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Sevene, E.
    Univ Eduardo Mondlane, Fac Med, Maputo, Mozambique; Manhica Hlth Res Ctr CISM, Manhica, Mozambique.
    Obstetric fistulae in southern Mozambique, incidence, risk factors and obstacles for care2017In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 124, no S1, p. 49-49Article in journal (Other academic)
  • 16.
    Mocumbi, Sibone
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Univ Eduardo Mondlane UEM, Fac Med, Dept Obstet & Gynaecol, Av Agostinho Neto 679, Maputo 1100, Mozambique..
    Hanson, Claudia
    Karolinska Inst, Dept Publ Hlth Sci, Tomtebodavagen 18A,Plan 4, Stockholm, Sweden.;London Sch Hyg & Trop Med, Dept Dis Control, Keppel St, London WC1E 7HT, England..
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Boene, Helena
    CISM, Rua 12,Vila Manhica, Manhica 1121, Mozambique..
    von Dadelszen, Peter
    Kings Coll London, Global Womens Hlth, London, England..
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. UCL, Inst Global Hlth, Gower St, London WC1E 6BT, England..
    Munguambe, Khtia
    UEM, Fac Med, Dept Publ Hlth, Av Salvador Allende 702 R-C, Maputo, Mozambique..
    Sevene, Esperanca
    UEM, Fac Med, Clin Pharmacol, Dept Physiol Sci, Av Salvador Allende 702 R-C, Maputo, Mozambique..
    Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment2017In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, article id 147Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair.

    METHODS: We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12-49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software.

    RESULTS: Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16-0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed.

    CONCLUSION: This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.

  • 17.
    Mocumbi, Sibone
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique.
    McKee, Kevin
    Munguambe, Khátia
    Chiau, Rogério
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Hanson, Claudia
    Wallin, Lars
    Sevene, Esperança
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Ready to deliver maternal and newborn care?: Health providers' perceptions of their work context in rural Mozambique2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1532631Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

    OBJECTIVES: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

    METHODS: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach's α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

    RESULTS: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

    CONCLUSIONS: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants' responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

  • 18.
    Pallangyo, Eunice N.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. School of Nursing and Midwifery, Aga Khan University, Salama House, 344 Urambo Street, P.O.BOX 38129, Dar es Salaam, Tanzania.
    Mbekenga, Columba
    School of Nursing and Midwifery, Aga Khan University, Salama House, 344 Urambo Street, P.O.BOX 38129, Dar es Salaam, Tanzania.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Implementation of a facilitation intervention to improve postpartum care in a low resource suburb in Dar es Salaam, Tanzania2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 102Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of evidence into practice is inadequate in many low-income countries, contributing to the low-quality care of mothers and newborns. This study explored strategies used in a facilitation intervention to improve postpartum care (IPPC) in a low-resource suburb in Dar es Salaam, Tanzania. The intervention was conducted during 1 year in government-owned health institutions providing reproductive and child health services. The institutions were divided into six clusters based on geographic proximity, and the healthcare providers of postpartum care (PPC) (n = 100) in these institutions formed IPPC teams. Each team was supported by a locally recruited facilitator who was trained in PPC, group dynamics, and quality improvement. The IPPC teams reflected on their practices, identified problems and solutions for improving PPC, enacted change, and monitored the adopted actions.

    Methods

    A qualitative design was employed using data from focus group discussions with healthcare providers (n = 8) and facilitators (n = 2), and intervention documentation. The discussions were conducted in Kiswahili, lasted for 45–90 min, were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis guided the analysis.

    Results

    Four main strategies were identified in the data: (1) Increasing awareness and knowledge of PPC by HCPs and mothers was an overarching strategy applied in training, meetings, and clinical practice; (2) The mobilization of professional and material resources was achieved through unleashing of the IPPC teams’ own potential to conduct PPC and act as change agents; (3) Improving documentation and communication; and (4) Promoting an empowering and collaborative working style were other strategies applied to improve daily care routines. The facilitators encouraged teamwork and networking among IPPC teams within and between institutions.

    Conclusion

    This facilitation intervention is a promising approach for implementing evidence and improving quality of PPC in a low-resource setting. Context-specific actions taken by the facilitators and healthcare providers are likely integral to the successfulness of implementing evidence into practice. The results contribute to increasing the understanding of facilitation as an intervention and can be useful for researchers, HCPs, and policymakers when improving quality of postpartum care, particularly in low-income settings.

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