Effect of checklist based box system interventions on improving institutional delivery among reproductive age women in Northwest Ethiopia: generalized structural equation modeling

Background Previous studies have shown that there is low utilization of institutional delivery in Ethiopia, as well as various factors contributing to this low utilization. Notably, there is paucity around interventions to improve institutional delivery. Hence, this study examines the effectiveness of checklist-based box system intervention on improving institutional delivery and to investigate the association through which the intervention is linked to institutional delivery. Method The study used data from a larger trial, on the effectiveness of checklist-based box system intervention on improving maternal health service utilization. In the intervention arm, mothers received regular community-level pregnancy screening and referral, service utilization monitoring boxes, drop-out tracing mechanisms, regular communication between health centers and health posts, and person-centered health education for mothers. This study used the existing government-led maternal health program as a control arm. A total of 1062 mothers who gave birth one-year before the survey were included in the final analysis. A difference-in-difference estimator was used to test the effectiveness of the intervention. Generalized structural equation modeling was used to examine the direct and/ indirect associations between the intervention and institutional delivery. Result Among participants, 403 (79.5%) mothers from intervention and 323 (58.2%) mothers from control clusters gave birth at health facilities. The result of the study revealed a 19% increase in institutional delivery in the intervention arm (19, 95%CI: 11.4-27.3%). In this study the pathway from checklist-based box system intervention to institutional delivery was mainly direct - (AOR = 3.32, 95%CI: 2.36-4.66), however, 33% of the effect was partially mediated by attendance of antenatal care four visits (AOR = 1.39, 95%CI: 1.02-1.92). The influence of significant others (AOR = 0.25, 95%CI: 0.15-0.43) and age (AOR = 0.03, 95%CI: 0.01- 0.09) had an inverse relation with institutional delivery. Conclusion The implementation of a checklist-based box system significantly increased institutional delivery utilization, both directly and indirectly by improving antenatal care four attendance. A larger-scale implementation of the intervention was recommended, taking the continuum of care approach into account. Trial registration ClinicalTrials.gov, NCT03891030, Retrospectively registered on 26 March, 2019.

Effectiveness of checklist-based box system intervention (CBBSI) versus routine care on improving postnatal care utilization in Northwest Ethiopia: a cluster randomized controlled trial

Background The period after childbirth poses a substantial risk both to the mother and the newborn. Yet, this period received less attention as compared to the cares provided during pregnancy and childbirth. Hence, this study aimed to assess the effectiveness of checklist-based box system intervention on improving three postnatal care visit utilization. Methods A double blind, parallel group, two-arm cluster randomized controlled trial design was used to assess effectiveness of checklist-based box system intervention on improving third postnatal care visit. Pregnant mothers below 16 weeks of gestation were recruited from 15 intervention and 15 control clusters, which were randomized using simple randomization. Data from baseline and end line surveys were collected using open data kit and analyzed using STATA version 15.0. The status of three postnatal care visit between intervention and control groups over time was assessed using difference in difference estimator. The predictors of the outcome variable were then analysed using mixed effects multilevel logistic regression model. Result Of 1200 mothers considered from each of the baseline and end line studies, this study included data from 1162 and 1062 mothers at baseline and end line surveys, respectively. As it is shown from the difference-in-difference estimation (14.8%, 95%CI 5.4–24.2%, p = 0.002) and the final model (AOR 4.45, 95%CI 2.31–8.54), checklist-based box system intervention was effective on improving third postnatal care visit. In addition, institutional delivery (AOR 1.62, 95%CI 1.15–2.28) and knowledge on danger signs during postnatal period (AOR 5.20, 95%CI 3.71–7.29) were found to be significant predictors of the outcome variable. In the contrary, mothers who got influenced by older generations of individuals were (AOR 0.32, 95%CI 0.18–0.59) less likely to attend three postnatal care visit. Conclusions The implementation of checklist-based box system intervention was found to be effective in improving utilization of the recommended three postnatal care visits. The contribution of the trial on improving third postnatal care visit can be enhanced by minimizing practical level challenges, as well as expanding health messages to reach unreached mothers and significant others who can influence the mother’s decision. Trial registration: ClinicalTrials.gov, NCT03891030, Retrospectively registered on 26 March, 2019, https://clinicaltrials.gov/ct2/show/NCT03891030.

System intervention in community pharmacy setting: Leading to better patient care through reducing harm associated with coprescribing benzodiazepines and opioids

Objective: The opioid epidemic is frequently discussed including the staggering numbers involved with coprescribing opioids and benzodiazepines associated with death. Community pharmacists, with the help of a system intervention, have a unique opportunity to help reduce the coprescribing of benzodiazepines and opioids and reduce the associated risk of death.Design: A single center retrospective chart review was conducted after a system intervention was placed, as a quality improvement project, from November 2019 to May 2020.Setting: Independent community pharmacy.Patients/participants: Data included demographics, dosing of each medication pre- and post-intervention, and naloxone status.Main outcome(s) measures: The primary outcome evaluated was reduction in dose/discontinuation of these prescriptions. The secondary outcome evaluated was the number of naloxone prescriptions ordered per protocol and picked up.Results: The primary outcome did not show statistical difference; however, the secondary outcomes showed statistical significance.Conclusion: In conclusion, community pharmacists, with the help of evolving technologies, can reduce harm associated with the coprescribing of benzodiazepines and opioids.

Developing Plans for Change

Chapter 5 presents a semi-structured plan for each work group to produce one system intervention plan (SIP) for their country. Taking the components of their health system, its underlying system problems, and their formulation of its vision and goals, the students individually and then in their small group take a stab at identifying gaps and constructing a system improvement plan. This chapter will present various techniques and exercises to help students come up with interventions that work. The process of idea-generating is designed to generate a solution to fix one or more of their chosen system performance gaps. The students’ work product is to agree on and propose one intervention to achieve the goals, objectives, and targets they have selected for their chosen country in Chapter 4.