scholarly journals A protocol for evaluating a multi-level implementation theory to scale-up obstetric triage in referral hospitals in Ghana

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Caitlin R. Williams ◽  
Stephanie Bogdewic ◽  
Medge D. Owen ◽  
Emmanuel K. Srofenyoh ◽  
Rohit Ramaswamy
Keyword(s):  
Scale Up ◽  
Implementation Theory ◽  
Referral Hospitals ◽  
Multi Level

A protocol for evaluating a multi-level implementation theory to scale up obstetric triage in referral hospitals in Ghana

2020 ◽  
Author(s):  
Caitlin Rain Williams ◽  
Stephanie Bogdewic ◽  
Medge Owen ◽  
Emmanuel K. Srofe ◽  
Rohit Ramaswamy
Keyword(s):  
Mixed Methods ◽  
Scale Up ◽  
Implementation Strategies ◽  
Clinical Intervention ◽  
Interactive Systems ◽  
Interactive Systems Framework ◽  
Implementation Theory ◽  
Care Plans ◽  
Implementation Approach ◽  
Multi Level

Abstract Background: Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan. Methods: An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions.A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability.Discussion: The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the “know-do” gap.

scholarly journals A protocol for evaluating a multi-level implementation theory to scale up obstetric triage in referral hospitals in Ghana

2020 ◽  
Author(s):  
Caitlin Rain Williams ◽  
Stephanie Bogdewic ◽  
Medge Owen ◽  
Emmanuel K. Srofe ◽  
Rohit Ramaswamy
Keyword(s):  
Mixed Methods ◽  
Scale Up ◽  
Implementation Strategies ◽  
Clinical Intervention ◽  
Interactive Systems ◽  
Interactive Systems Framework ◽  
Implementation Theory ◽  
Care Plans ◽  
Implementation Approach ◽  
Multi Level

Abstract Background Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan. Methods An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions. A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability. Discussion The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the “know-do” gap.

scholarly journals FACTORS INFLUENCING CLINICAL MANAGEMENT OF CRYPTOCOCCAL MENINGITIS AMONG HEALTH CARE PROVIDERS AT TWO REFERRAL HOSPITALS IN KISUMU COUNTY, KENYA

2021 ◽  
Vol 7 (1) ◽  
pp. 74-84
Author(s):  
Robina Ogendo
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Cryptococcal Meningitis ◽  
Clinical Management ◽  
Scale Up ◽  
World Health ◽  
Unique Contribution ◽  
Care Providers ◽  
Factors Influencing ◽  
Referral Hospitals

Purpose: Cryptococcal meningitis is one of the most common and lethal opportunistic infections among human immune virus infected clients/patients before initiation of antiretroviral therapy. It is majorly associated to morbidity and early mortality among human immunodeficiency virus infected patients in resource limited countries. The main objective of this study was to investigate the factors influencing clinical management of cryptococcal meningitis in adults among health care providers at two referral hospitals in Kisumu County, Kenya. Methodology: A cross-sectional study using quantitative approach was used targeting 119 health care providers. Collection of data was through pretested self- administered questionnaires to examine factors influencing clinical management of cryptococcal meningitis. Data obtained was analyzed using the statistical package for social science version 25. Descriptive analysis was done using frequencies, percentages and means. Inferential analysis was conducted using bivariate logistic regression to determine relationships among the variables, p-values of at or below 0.05 were considered statistically significant. Results: The major factor associated positively with clinical management of cryptococcal meningitis was the acknowledgement by the health care providers that the world health organization guidelines lead to a better patient outcome (97%, n=113) and inadequate supplies and resources to facilitate management (78%, n=90) was the major factor associated negatively. Health care providers with an experience of five years or less were 40% more likely to agree that the factors were influencing clinical management of cryptococcal meningitis in contrast to those with an experience of six years or more (OR: 0.6; 95%CI: 0.1 – 0.74; p=0.04). Unique contribution to theory, practice and policy:  The clinical management of cryptococcal meningitis in adults in the study area is majorly negatively influenced by inadequate supplies and resources to facilitate the process of management. The study recommends that the policy makers in the County government of Kisumu and the two hospital management teams need to scale up a timely and constant provision of adequate resources, facilities and supplies, which will promote effective clinical management of cryptococcal meningitis in the study area

scholarly journals High rates of culture conversion and low loss to follow-up in MDR-TB patients managed at Regional Referral Hospitals in Uganda

2019 ◽  
Author(s):  
Martin Kayitale Mbonye ◽  
John-Paul Otuba ◽  
Sara Riese ◽  
Hilary Alima ◽  
Frank Mugabe ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Treatment Initiation ◽  
Scale Up ◽  
Health Concern ◽  
Cross Sectional ◽  
Tb Treatment ◽  
Referral Hospitals ◽  
Mdr Tb ◽  
Lost To Follow Up

Abstract Background: Multi-drug resistant – tuberculosis (MDR-TB) is an emerging public health concern in Uganda. Prior to 2013, MDR-TB treatment in Uganda was only provided at the national referral hospital and two private-not-for profit clinics. From 2013, it was scaled up to seven regional referral hospitals (RRH). The aim of this study was to measure interim (six months) treatment outcomes among the first cohort of patients started on MDR-TB treatment at the RRH in Uganda. Methods: This was a cross-sectional study in which a retrospective descriptive analysis of data on a cohort of 69 patients started on MDR-TB treatment at 7 RRH between 1st April 2013 and 30th June 2014 and had been on treatment for at least nine months was conducted. Results: Of the 69 patients, 21 (30.4%) were female, 39 (56.5%) HIV-negative, 30 (43.5%) resistant to both isoniazid and rifampicin and 57 (82.6%) category 1 or 2 drug susceptible TB treatment failures. Median age at start of treatment was 35 years (Interquartile range (IQR): 27-45), median time-to-treatment initiation was 27.5 (IQR:6-89) days and of the 30 HIV-positive patients, 27 (90.0%) were on anti-retroviral treatment with a median CD4 count of 206 cells/microliter of blood (IQR: 113-364.5). Within six months of treatment, 59 (86.0%) patients culture converted, of which 45 (65.2%) converted by the second month and the other 14 (20.3%) by the sixth month; one (1.5%) did not culture convert; three (4.4%) died; and six (8.8%) were lost-to-follow up. Fifty (76.8%) patients experienced at least one drug adverse event, while 40 (67.8%) gained weight. Mean weight gained was 4.7 (standard deviation:3.2) kilograms. Conclusions: Despite MDR-TB treatment initiation delays, most patients had favourable interim treatment outcomes with majority culture converting early and very few getting lost to follow-up. These encouraging interim outcomes indicate a successful scale-up of MDR-TB treatment to RRH.

scholarly journals Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

2020 ◽  
Author(s):  
HENRY ZAKUMUMPA ◽  
Joseph Rujumba ◽  
Japheth Kwiringira ◽  
Cordelia Katureebe ◽  
Neil Spicer
Keyword(s):  
Supply Chain ◽  
Health System ◽  
National Level ◽  
Scale Up ◽  
World Health ◽  
Community Factors ◽  
Individual Level ◽  
Multi Level ◽  
Art Delivery ◽  
Selection Of

Abstract Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART delivery in Uganda. Methods We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

scholarly journals High rates of culture conversion and low loss to follow-up in MDR-TB patients managed at Regional Referral Hospitals in Uganda

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Mbonye Kayitale Martin ◽  
Otuba John Paul ◽  
Riese Sara ◽  
Alima Hilary ◽  
Mugabe Frank ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Treatment Initiation ◽  
Scale Up ◽  
Health Concern ◽  
Cross Sectional ◽  
Tb Treatment ◽  
Referral Hospitals ◽  
Mdr Tb ◽  
Lost To Follow Up

Abstract Background Multi-drug resistant—tuberculosis (MDR-TB) is an emerging public health concern in Uganda. Prior to 2013, MDR-TB treatment in Uganda was only provided at the national referral hospital and two private-not-for profit clinics. From 2013, it was scaled up to seven regional referral hospitals (RRH). The aim of this study was to measure interim (6 months) treatment outcomes among the first cohort of patients started on MDR-TB treatment at the RRH in Uganda. Methods This was a cross-sectional study in which a descriptive analysis of data collected retrospectively on a cohort of 69 patients started on MDR-TB treatment at six of the seven RRH between 1st April 2013 and 30th June 2014 and had been on treatment for at least 9 months was conducted. Results Of the 69 patients, 21 (30.4%) were female, 39 (56.5%) HIV-negative, 30 (43.5%) resistant to both isoniazid and rifampicin and 57 (82.6%) category 1 or 2 drug susceptible TB treatment failures. Median age at start of treatment was 35 years (Interquartile range (IQR): 27–45), median time-to-treatment initiation was 27.5 (IQR: 6–89) days and of the 30 HIV-positive patients, 27 (90.0%) were on anti-retroviral treatment with a median CD4 count of 206 cells/microliter of blood (IQR: 113–364.5). Within 6 months of treatment, 59 (85.5%) patients culture converted, of which 45 (65.2%) converted by the second month and the other 14 (20.3%) by the sixth month; one (1.5%) did not culture convert; three (4.4%) died; and six (8.8%) were lost-to-follow up. Fifty (76.8%) patients experienced at least one drug adverse event, while 40 (67.8%) gained weight. Mean weight gained was 4.7 (standard deviation: 3.2) kilograms. Conclusions Despite MDR-TB treatment initiation delays, most patients had favourable interim treatment outcomes with majority culture converting early and very few getting lost to follow-up. These encouraging interim outcomes indicate the potential for success of a scale-up of MDR-TB treatment to RRH.

scholarly journals Analysing the socio-technical transition to conservation agriculture in Uganda through the lens of the multi-level perspective

2020 ◽  
Author(s):  
Sara Helen Kaweesa ◽  
Hamid El Bilali ◽  
Willibald Loiskandl
Keyword(s):  
National Level ◽  
Scale Up ◽  
Conservation Agriculture ◽  
Scientific Publications ◽  
Conventional Agriculture ◽  
Legal Standards ◽  
Research Findings ◽  
Multi Level ◽  
Civic Awareness ◽  
The Impact

Abstract Conservation agriculture (CA) is based on three principles, namely minimum tillage, crop rotations and maintaining a soil cover. The research used the multi-Level perspective on socio-technical transitions to analyse the dynamics of CA in Uganda. The analysis of the CA niche is structured along the socio-technical regimes and explores the impact of the transition. Data were gathered from Alebtong, Dokolo and Lira districts in mid-Northern Uganda. The results indicate a steady transition towards CA that can be supported to eventually scale up. The legitimisation process of CA transition involved wider implementation by farmers on their fields, validation through adoption by the wider communities and at the national level. The process seeks policy and institutional promotion, more scientific publications of local research findings, validation by legal standards and judicial reasoning, raising civic awareness, stakeholder dialogue and mobilisation of political will to advance the purposes of CA in contrast to conventional agriculture. CA caused changes in practices, perceptions and motivation among the niche actors with respect to agricultural sustainability. However, scaling up could further be enhanced when market policies, credit and financial environment are reconciled.

scholarly journals Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

2020 ◽  
Author(s):  
HENRY ZAKUMUMPA ◽  
Joseph Rujumba ◽  
Japheth Kwiringira ◽  
Cordelia Katureebe ◽  
Neil Spicer
Keyword(s):  
Supply Chain ◽  
Health System ◽  
National Level ◽  
Scale Up ◽  
World Health ◽  
Community Factors ◽  
Individual Level ◽  
Multi Level ◽  
Art Delivery ◽  
Selection Of

Abstract Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART delivery in Uganda. Methods We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported as an impediment to the running of patient groups of rotating ART refill pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

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