Delivery Of Reproductive Health Services Research Articles

How to Enhance Effective Delivery of Quality Adolescent Sexual and Reproductive Health Services in Ghana

How to Enhance Effective Delivery of Quality Adolescent Sexual and Reproductive Health Services in Ghana

Skin tone discrimination and birth control avoidance among women in Harris County, Texas: a cross-sectional study

IntroductionStructural racism plays a major role in reproductive health inequities. Colorism, discrimination based on skin color, may profoundly impact reproductive health access and service delivery. However, quantitative research in this area is limited.MethodsWe administered an online survey of women (n = 1,299) aged 18–44 from Harris County, Texas to assess the relationship between skin color discrimination and reproductive health service avoidance. The survey included questions on demographics, self-reported skin tone, and dichotomous measures of previous discrimination experiences and avoidance of care because of perceived discrimination. Binary logistic regression was used to examine whether race/ethnicity, skin tone, and previous discrimination experiences were related to avoidance of contraceptive care because of perceived discrimination.ResultsApproximately one-third (31.5%) of the sample classified themselves as non-Hispanic Whites (31.5%), 22.4% as Black, 27.4% as Hispanic and born within the US, and 7.6% as Hispanic born outside of the US. Approximately one-third of women classified themselves in the lightest skin tones, whereas almost one in five women classified themselves in the darkest skin tone palates. Darker skin tones had increasingly greater odds of reporting that they avoided seeking birth control out of a concern for discrimination compared to the lightest skin tone. After adjusting for race/ethnicity and sociodemographic variables (model 3), darker skin tones remained significantly associated with avoiding birth control.DiscussionThis study demonstrates the role that skin color discrimination plays in negative reproductive health experiences. While this is not surprising given that those with racist ideologies developed the concept of these racial and ethnic categories, the apparent association with darker skin colors and avoidance of seeking birth control provides evidence that structural and individual racism continues to have far-reaching and insidious consequences.ConclusionContraception is recognized for reducing maternal mortality, improving child health, increasing female empowerment, and decreasing poverty. However, not all women equally enjoy the benefits of access to contraception. Addressing colorism within reproductive healthcare has become critically important as the nation becomes increasingly diverse. Focusing on skin tone-based discrimination and its roots in anti-blackness expands our understanding beyond a Black–White binary traditionally applied when addressing racism in healthcare delivery.

Rights-based sexual and reproductive health services: a call for improved access for youth.

Constituting a valuable resource, youth deserve more attention regarding their rights through increased access to sexual and reproductive health services. Limitations in health service delivery for youth should be overcome, whether pertaining to restrictive legislation and policies or technical approaches. Clear clinical guidelines will improve quality of care thereby complying with national commitments to international legal instruments. It is apt for both decision-makers and service providers to celebrate International Youth Day on Monday 12 August, by paying special consideration to innovative approaches for the delivery of youth-friendly sexual and reproductive health services that are adaptable to local circumstances.

Perspectives from the frontline: Nurses’ experiences of adolescent engagement in sexual and reproductive health services

Background: Nurses have a critical role to play in the delivery of sexual and reproductive health (SRH) services to adolescents and young people. Nurses’ interactions with adolescents and young people can shape sexual and reproductive behaviours and outcomes, including willingness to access and engage with healthcare services. However, little research from low- and middle-income contexts has explored nurses’ firsthand perspectives regarding their relationships with adolescents and young people in the context of SRH service provision, especially since the COVID-19 pandemic. Aim: This study explored nurses’ perceptions of working with adolescents and young people as well as how these impressions manifest in one-on-one exchanges between nurses and young patients. Method: Semi-structured interviews were conducted with 20 nurses providing SRH services to adolescents and young people and based at public health facilities in urban, peri-urban and rural areas within a health sub-district of the Eastern Cape province of South Africa. Data were analysed using an inductive thematic approach. Results: While many nurses described the challenges facing adolescents and young people in an empathic way and expressed a desire and willingness to engage with and educate them, some found it ‘difficult to break through’. Nurses linked this difficulty to the shame adolescents and young people feel when discussing SRH concerns, but also to them having ‘attitude’ and ‘not listening’. Findings highlight how while nurses may genuinely care about providing services to their young patients, internal and social biases may impact their motivation and willingness to effectively support adolescents and young people within the context of SRH service provision. To improve patient–provider relations, we suggest a focus on practical and participatory interventions to improve interpersonal dynamics.

Client satisfaction and contributing factors towards sexual and reproductive health services delivery system among youth at Family Guidance Association of north Ethiopia (FGAE) clinics, 2023: mixed method study

BackgroundThe Family Guidance Association of Ethiopia (FGAE) operates as a non-governmental organization dedicated to offering family planning and reproductive health services to the Ethiopian population. The gap in the study regarding client satisfaction and contributing factors towards sexual and reproductive health services for youth at FGAE clinics highlights the need for a comprehensive investigation to fill this void. By conducting a mixed-method study, this research aims to provide a holistic understanding of the factors influencing client satisfaction in the delivery of sexual and reproductive health services to youth at FGAE clinics. The added value of this study lies in its potential to offer valuable insights and recommendations for improving service delivery systems and enhancing client satisfaction levels, ultimately contributing to the overall well-being and health outcomes of youth in North Ethiopia. Therefore study aimed to asses Client Satisfaction and Contributing Factors towards in sexual and reproductive health services delivery system among youth at Family Guidance Association of North Ethiopia (FGAE) Clinics, 2023.MethodThe study was conducted within the clinics of the Family Guidance Association of Ethiopia (FGAE), spanning Dessie, Kombolcha, and Woldia city administrations, involving a participant cohort of 416 clients. Facility-based concurrent type mixed method study design both quantitative and qualitative techniques were applied. Quantitative research employed a simple random sampling technique and conversely, the qualitative study utilized a heterogeneous type of purposive sampling strategy to recruit participants The collected data underwent a rigorous process of entry, cleaning, and coding using Epi-Data 4.6 software, followed by analysis in STATA V17. Descriptive statistics and binary logistic regression were employed to highlight the impact of independent variables on the dependent variable. A more comprehensive examination was provided through multivariable logistic regression. Crude and adjusted odds ratios, along with a 95% confidence interval, were computed, with significance set at a p-value ≤ 0.05.ResultNearly more than half of the clients 194 (47.8%) came to receive family planning services followed by maternal and child health 107 (26.4%). Sixty patients (14.8%) didn’t receive all the services they wanted or came for. Half of the participants 30 (50%) raised the unavailability of the service as a reason for not taking the service followed by not having enough time in the clinic 12 (20%). About 65.52% (60.74-70.00%) of the participants were satisfied with the Sexual and Reproductive Health services provided by the clinics of FGAE in northeast Ethiopia. Clients in the age group of 25–34 (AOR = 2.04; 95%CI: 1.11–3.72). Clients who had primary and secondary education (AOR = 2.49; 95%CI: 1.03–6.02) and (AOR = 3.05; 95%CI: 1.25–7.49) respectively. Clients who responded that physicians show respect (AOR = 5.59; 95%CI: 1.89–16.49). clients who received an explanation about the side effects of the utilized methods and follow-up dates (AOR = 4.59;95%CI:1.68–12.53) and (AOR = 2.89;95%CI:1.53–5.49) respectively.ConclusionThe proportion of client satisfaction with Client Satisfaction in the Services delivery system at Family Guidance Association of Ethiopia (FGAE) Clinics was low as compared to the previous study. Age group 25–34 years, primary and secondary education, showing respect, explaining side-effects and follow-up visits were significant associated factors of client service satisfaction. Enhancing service delivery at Family Guidance Association of Ethiopia (FGAE) Clinics by targeting specific areas identified in the study. Strategies should focus on improving communication regarding side effects, ensuring respectful interactions, and prioritizing follow-up visits, particularly for clients aged 25–34 with primary and secondary education backgrounds.

Meeting the reproductive health needs of female sex workers in Côte d’Ivoire: protecting the human right to dignified health

The sexual and reproductive health needs of female sex workers (FSW) are often understudied and underserved in the context of HIV-related research in countries across Sub-Saharan Africa and West Africa. We assessed the lived experiences of FSW across Côte d’Ivoire to characterize unmet reproductive health needs and opportunities to address them. From February-August, 2020, ENDA Santé, Côte d’Ivoire conducted 75 in-depth interviews and 15 focus group discussions with FSW and community informants in five cities in Côte d'Ivoire. Themes that emerged included the inconsistent use of contraception services, a history of unintended pregnancies, and experiences of stigma at public healthcare facilities. Opportunities to increase the impact of both SRH and HIV services included strengthening existing HIV and family planning service integration for FSW. Taken together, the results highlight the importance of addressing the unmet reproductive health needs of FSW to both optimize the HIV response and increase the delivery of human-rights affirming sexual and reproductive health services for sex workers.

Personal data governance and privacy in digital reproductive, maternal, newborn, and child health initiatives in Palestine and Jordan: a mapping exercise.

There is a rapid increase in using digital technology for strengthening delivery of reproductive, maternal, newborn, and child health (RMNCH) services. Although digital health has potentially many benefits, utilizing it without taking into consideration the possible risks related to the security and privacy of patients' data, and consequently their rights, would yield negative consequences for potential beneficiaries. Mitigating these risks requires effective governance, especially in humanitarian and low-resourced settings. The issue of governing digital personal data in RMNCH services has to date been inadequately considered in the context of low-and-middle-income countries (LMICs). This paper aimed to understand the ecosystem of digital technology for RMNCH services in Palestine and Jordan, the levels of maturity of them, and the implementation challenges experienced, particularly concerning data governance and human rights. A mapping exercise was conducted to identify digital RMNCH initiatives in Palestine and Jordan and mapping relevant information from identified initiatives. Information was collected from several resources, including relevant available documents and personal communications with stakeholders. A total of 11 digital health initiatives in Palestine and 9 in Jordan were identified, including: 6 health information systems, 4 registries, 4 health surveillance systems, 3 websites, and 3 mobile-based applications. Most of these initiatives were fully developed and implemented. The initiatives collect patients' personal data, which are managed and controlled by the main owner of the initiative. Privacy policy was not available for many of the initiatives. Digital health is becoming a part of the health system in Palestine and Jordan, and there is an increasing use of digital technology in the field of RMNCH services in both countries, particularly expanding in recent years. This increase, however, is not accompanied by clear regulatory policies especially when it comes to privacy and security of personal data, and how this data is governed. Digital RMNCH initiatives have the potential to promote effective and equitable access to services, but stronger regulatory mechanisms are required to ensure the effective realization of this potential in practice.

Healthcare workers’ delivery of adolescent responsive sexual and reproductive healthcare services: an assessment in Plateau state, Nigeria

BackgroundAdolescents should have access to high quality and responsive sexual and reproductive health, however, it is unclear to what extent the national policy on health and development of adolescent is implemented by health care workers in Plateau State. This study assessed the general availability of sexual and reproductive health services, the delivery of responsive adolescent sexual and reproductive health services and health care worker?s understanding of what constitutes adolescent responsive sexual and reproductive health services.MethodsUsing a cross sectional design, we interviewed 409 health care workers selected through a multistage sampling technique, across six Local Government Areas of Plateau State, Nigeria using an interviewer-administered survey questionnaire.ResultsThe most available sexual and reproductive health services was antenatal and delivery care (69.2%), contraception 25.9% and 14.9% reported post abortion care. Only 1.2% indicated the availability of the four recommended essential sexual and reproductive health services (counselling/information provision, provision of contraceptives, testing/treatment for sexually transmitted infection (STI) /HIV and post abortion care) in their facilities. Little over half (58.4%) felt their facilities were adequate in meeting the sexual and reproductive health needs of adolescent and this was associated with delivery of post abortion care (AOR=3.612; CI=1.886-6.917; p = .001) and providing sexual and reproductive health services to adolescents without parental consent (AOR=3.612; CI=1.886-6.917; p = .001). Most health care workers had poor understanding of adolescent responsiveness of sexual and reproductive health services, understanding better among health workers who provided services without parental consent and in a separate room for privacy and confidentiality.ConclusionWe conclude that adolescent sexual and reproductive health services is not yet as stipulated in the national policy in Plateau State, Nigeria and in general, health workers have poor understanding of what it means to provide adolescent-responsive services.

The role of midwives in implementing reproductive health services in Islamic Republic of Iran.

It is essential to study the availability of reproductive health services and the capacities of providers, to provide evidence for improving service quality. To identify the role of midwives in the provision of reproductive health services and recommend improvements. A national review of government health resources in the Islamic Republic of Iran was conducted to explore available reproductive health services. Through semi-structured interviews with 30 midwives, information was collected about the compatibility of services with the capacity and scope of the activities of midwives. A panel of 12 experts was assembled to develop a proposed service package. The content analysis method was applied to data analysis and interpretation. The service package developed covered 82 services that midwives can offer at the 8 healthcare facility groups. Although midwives were trained to manage a range of primary and gynaecological care services, certain essential aspects of reproductive health services were not being delivered on the frontline. These include sexually transmitted diseases and human papilloma virus management, diagnosis and treatment of common gynaecological problems, sexual education and counselling, and childbirth services. Midwives were not adequately engaged to provide reproductive health care at the secondary level. There are drawbacks to the current reproductive health service delivery in the Islamic Republic of Iran. The service package designed and proposed in this study aims to strengthen reproductive health care services and planning and better integration of midwife-led programmes.

Community and Health Care Provider Perspectives on Barriers to and Enablers of Family Planning Use in Rural Sindh, Pakistan: Qualitative Exploratory Study.

Unmet need for family planning in Pakistan is high, with 17% of all married women wanting to avoid or delay pregnancy. However, they cannot owing to a lack of access to modern contraception and sociocultural hindrances. With the modern contraceptive prevalence rate stagnant at approximately 25% over the last 5 years, it is important to explore barriers and enablers to modern contraception uptake to reduce maternal and child mortality and improve reproductive health outcomes for young girls and women. A formative research approach was taken to explore community member and health care provider perspectives on access to and use of family planning methods in 2 rural districts of Sindh, Pakistan. The broader goal of this study was to provide evidence to design and implement a socioculturally appropriate family planning intervention within the existing service delivery platforms to increase modern contraceptive uptake in the context of rural Sindh. A qualitative exploratory design was used. Between October 2020 and December 2020, 11 focus group discussions and 11 in-depth interviews were conducted. Focus group discussions were held with men and women from the community, including adolescents, to build an understanding of community beliefs and concepts regarding modern contraceptive methods. In-depth interviews were conducted with health care workers and explored intersections between family planning and reproductive health service delivery at the facility and outreach levels. The findings revealed that limited financial autonomy, restricted women's mobility, discriminatory gender norms, and cultural practices left women with little opportunity for independent decision-making on the use of modern contraceptive methods. Furthermore, facility-level and supply-side barriers, including frequent stock-outs of modern contraceptives combined with a lack of capacity of health workers to provide quality family planning services and counseling, played an important role in demotivating women from seeking services. In addition, a lack of integration of family planning with maternal and child health service delivery at the health system level was emphasized as a major missed opportunity for contraceptive uptake. Several demand-side barriers to family planning uptake were also highlighted. These included husbands' or in-laws' disapproval, social stigma, and perceived fear of side effects regarding modern family planning method use. More importantly, a lack of adolescent-friendly reproductive health services and spaces for counseling was identified as a critical intervention area. This study provides qualitative evidence on issues related to the effectiveness of family planning interventions, specifically in the context of rural Sindh. The findings emphasize the need to design socioculturally appropriate and health system-relevant family planning interventions-the effectiveness of which can be improved through their integration with maternal and child health service delivery mechanisms, consistent service provision, and opportunities for the capacity building of the health care workforce. RR2-10.2196/35291.

Identifying the gaps: Knowledge, attitudes and practices of urban-based healthcare providers towards adolescent contraception in Jamaica

Abstract Objective Health care providers (HCPs) may serve as facilitators or barriers to access. We explore the knowledge, attitudes and practices of HCPs in Jamaica to identify gaps which may lead to unmet contraceptive needs for adolescents. Methods A cross-sectional study design was utilized to collect data from urban-based HCPs through a self-administered questionnaire regarding knowledge of, attitudes towards and practices in adolescent contraception. Summative knowledge and attitude scores were generated. Descriptive and inferential statistical analyses were performed. Results One hundred and forty-four HCPs participated with a female predominance (n=127; 88.2%) and median (IQR) age of 36 (20) years old. HCPs mean (SD) knowledge score 1.95 (0.81) negatively correlated with age (r= -0.279; p<0.01) and length of time working as an HCP (r= -0.287; p<0.01). Pharmacy staff had lowest mean (SD) scores, 13.4 (4.48); p<0.05. Mean attitude score did not differ significantly by marital status or religion. As HCPs’ length of time in practice increased there was a decrease in the attitude scores (β= -0.380; p<0.05). Conclusion There is need for capacity-building of HCPs to deliver active contraceptive counselling and provide modern, effective, evidence-based contraceptive services to adolescents in Jamaica. Review and revision of guidelines, policies and laws governing delivery of sexual and reproductive health services is recommended. Key words: adolescents, contraception, providers, Latin America and the Caribbean

Clients' perspectives on the utilization of reproductive, maternal, neonatal, and child health services in primary health centers during COVID-19 pandemic in 10 States of Nigeria: A cross-sectional study.

Reports from various parts of the world suggest that the COVID-19 pandemic may have severe adverse effects on the delivery and uptake of reproductive health, maternal, neonatal, and child health (RMNCH) services. The objective of the study was to explore women's experiences with utilization of RMNCH services during the COVID-19 pandemic in Nigeria, and to elicit their perceptions on ways to sustain effective service delivery during the pandemic. A cross-sectional survey of 2930 women using primary health care facilities for antenatal, delivery, postnatal, and child care services before and after the onset of the pandemic in 10 States of Nigeria were interviewed with a semi-structured questionnaire. Data were collected on women's socio-demographic characteristics and pregnancy histories, the services they sought before and after the pandemic, the challenges they faced in accessing the services, their use of alternative sources of health care, and their recommendations on ways to sustain RMNCH service delivery during the pandemic. The data were analyzed with descriptive statistics, and multivariable logistic regression using SPSS 20.0. All the statistical analyses were two-tailed with a 95% confidence interval, and the p-value was set at 0.05. The logistic regression results showed that women were at least 56% more likely to report that they used family planning, antenatal, and delivery services before the pandemic than after the pandemic started, but 38% less likely to report use of postnatal services. The experience of difficulty accessing RMNCH services was 23% more likely after the pandemic started than before the pandemic. Three categories of recommendations made by the respondents on measures to sustain RMNCH delivery during the pandemic included 1) facility improvement, and staff recruitment and re-training; 2) free and readily accessible PHC services, and 3) the provision of social safety nets including transportation and palliatives. We conclude that the COVID-19 pandemic limited women's access to antenatal, delivery, and childcare services offered in PHCs in Nigeria. Addressing the recommendations and the concerns raised by women will help to sustain the delivery of RMNCH services during the COVID-19 pandemic and future epidemics or health emergencies in Nigeria.

My HIV Care – Preferences of people living with HIV for medicine-related support from community pharmacists

Abstract Introduction HIV is now a long-term condition, presenting new challenges for primary care providers. Hospital-based specialists have traditionally provided medicine-related support to people living with HIV (PLWH) within secondary care clinics,1 but with an aging population and rising polypharmacy2 other forms of support will be needed. Although community pharmacists (CPs) are already involved in sexual and reproductive health service delivery to varying magnitudes,3 it is unknown whether PLWH want them to be involved in their HIV treatment and medicine support. Aim To understand the pReferences and perceptions of PLWH towards CP involvement in their care. Methods An online survey, promoted to UK HIV charities and activists via social media (November 2021–July 2022), asked about pReferences for medicine-related support and the involvement of CPs in PLWH’s care. Questions explored factors that would influence use of CPs for all services. Views on sharing HIV diagnoses with CPs during medicine-related consultations were also obtained. Descriptive analysis was used. Institutional ethics approval was obtained. Results Approximately half (73/144) of those who accessed the survey fully completed it: 57.5% male; age 22-80 years. Of those who provided demographic data: 88.9%(n=48/54) were white; gay/lesbian (64.8%, n=35); University-level education (57.4%, n=31) and employed (55.6%, n=30). CPs were rated among the least helpful health professionals in terms of medicine support (2.7%, n=2) compared to general practitioners (13.7%, n=10), HIV clinic-based nurses (35.6%, n=26), specialist pharmacists (42.5%, n=31) or consultants (56.2%, n=41). Over half (56.1%, n=41) were unsure or did not want their CP to be involved in their HIV care. Patient autonomy/self-efficacy, mistrust, concerns around stigma and privacy/confidentiality of information shared in community pharmacy settings, and perceived lack of HIV-related knowledge among CPs influenced participants’ p

Maturity Level of Digital Reproductive, Maternal, Newborn, and Child Health Initiatives in Jordan and Palestine.

While there is a rapid increase in digital health initiatives focusing on the processing of personal data for strengthening the delivery of reproductive, maternal, newborn, and child health (RMNCH) services in fragile settings, these are often unaccompanied at both the policy and operational levels with adequate legal and regulatory frameworks. The main aim was to understand the maturity level of digital personal data initiatives for RMNCH services within fragile contexts. This aim was performed by choosing digital health initiatives from each country (two in Jordan and three in Palestine) based on RMNCH. A qualitative study design was adopted. We developed a digital maturity assessment tool assessing two maturity levels: the information and communications technology digital infrastructure, and data governance and interoperability in place for the five selected RMNCH initiatives in Jordan and Palestine. Overall, the digital infrastructure and technological readiness components are more advanced and show higher maturity levels compared with data governance and interoperability components in Jordan and Palestine. In Jordan, the overall Jordan stillbirths and neonatal deaths surveillance initiative maturity indicators are somehow less advanced than those of the Electronic Maternal and Child Health Handbook-Jordan (EMCH-J) application. In Palestine, the Electronic Maternal and Child Health-registry initiative maturity indicators are more advanced than both Avicenna and EMCH-Palestine initiatives. The findings highlighted several challenges and opportunities around the application and implementation of selected digital health initiatives in the provision of RMNCH in Jordan and Palestine. Our findings shed lights on the maturity level of these initiatives within fragile contexts. The maturity level of the five RMNCH initiatives in both countries is inadequate and requires further advancement before they can be scaled up and scaled out. Taking the World Health Organization recommendations into account when developing, implementing, and scaling digital health initiatives in low- and middle-income countries can result in successful and sustainable initiatives, thus meeting health needs and improving the quality of health care received by individuals especially those living in fragile contexts.

Non-Governmental Organisations and Health Service Delivery in The Gambia: A Case Study of The Hands-On-Care Clinic

This study mainly assessed the performance of the Hands-on-Care (HoC) Clinic, a Non-Governmental Organisation, in sexual and reproductive health service delivery in The Gambia and identified the challenges being faced by the organisation. Both primary and secondary data were used for this study. Primary data were collected using a questionnaire, in-depth interviews, and Participant Observation. The staff and patients of HoC Clinic and the two support societies were targeted for the study. The results of the study revealed that NGOs play vital roles in the delivery of health services. HoC Clinic has made and continues to make significant contributions to the sexual and reproductive health of The Gambia. The results also showed that it contributes individually and collectively in a participatory manner to improving the quality of life of all Gambians and non-Gambians alike. Based on the cumulative responses of staff, patients, and support societies and in consultation with relevant institutional documents, it could be observed that the institution continues to perform extremely well in the provision of sexual and reproductive health services to the people despite challenges in terms of human and material resources as alluded to by many respondents during the study. The performance of the institution was said to have been hindered by a poor commitment from the government, high reliance on donors, limited funding from other partners, and an unstable political environment, among others. The study concluded that NGOs play important roles in health service delivery, especially in developing countries where the government lacks the power to do all for its citizens. This makes them indispensable to the development of a country as they fill the gap the government is unable to fill.

Improving water, sanitation and hygiene (WASH) services in primary health care facilities in Edo State, Nigeria: A call for action.

Addressing water, sanitation, and hygiene (WASH) in health care facilities will foster action towards achieving the inter-related Sustainable Development Goals 3 and 6. WASH plays a significant role in sexual and reproductive health service delivery quality. Despite the relevance of WASH to reproductive health, quality of care, and disease control in Primary Health Care (PHC) facilities, accessibility is considerably low, with minimal attention given to the enormous yet solvable crisis of inadequacy of WASH in PHC facilities in Edo State. This paper provides insight on WASH status in PHC facilities in Edo State, identifies barriers to WASH provision, and practical steps to improving WASH services in the PHC facilities in Edo State. It was concluded that strict adherence to minimum standards for WASH facilities in PHCs should be ensured, and also a regular assessment of the availability and quality of WASH services in PHC facilities in Edo State should be conducted.

Evidence of Interventions and Strategies to Bridge the Quality Improvement Gap Led by HCW at the Frontline in SSA: A Scoping Review

Abstract Introduction Poor quality health care is a significant cause of preventable deaths, especially in low- and middle-income countries (LMICs). Quality improvement is multifaceted and includes strategies such as standard setting, quality assurance and clinic audits. In order to move quality improvement in health care into every day practice it is essential to fully engage the frontline where health care is delivered. The objective of this scoping review is to investigate front line health care worker line led quality improvement in Sub Saharan Africa (SSA). Methods We conducted a scoping review to identify, map and synthesize evidence on health care worker led quality improvement initiatives in Sub Sahara Africa using electronic databases PubMed, Cochrane, Embase, CINAHL, Scopus and Psychinfo to identify peer-reviewed literature published between January 2000 and January 2021. To identify grey literature, we used the same search terms in google search to a maximum of 10 pages or when there was no new information. All evidence was scored based on the 6 criteria described by Backhouse et al., which clearly distinguish quality improvement from clinical audit and research. Inclusion criteria were studies that involved frontline health care workers to test “change ideas” and used data systems to measure improvement in service delivery. Results A total of 75 records were identified and including 52 from the peer review search and 23 records from the grey literature search. Only 15 of 47 countries had publications (peer-review or grey literature) describing QI initiatives. Most quality improvement (QI) initiatives were multicomponent and included knowledge transfer, skills building, mentorship and learning visits. Most publications reported QI initiatives aimed at reproductive, maternal, neonatal and child health (n=23) and HIV (n=14) service delivery. Only 6 had experimental designs. No publications were identified prior to 2012 and a rapid escalation of published quality improvement initiatives from 2012 to 2020 was seen. Conclusion QI is in the very nascent stage in SSA. Most large-scale public health QI initiatives are sector specific, siloed, and donor driven. QI initiatives within sector specific programs have not moved horizontally and have had limited ability to change the broader system. Energy must be exerted to change the status quo. Making health care safer and more effective is not spontaneous.

Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings.

Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients. We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings. Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments. Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.

The impact of training on self-reported performance in reproductive, maternal, and newborn health service delivery among healthcare workers in Tanzania: a baseline- and endline-survey

BackgroundDelivery of quality reproductive health services has been documented to depend on the availability of healthcare workers who are adequately supported with appropriate training. However, unmet training needs among healthcare workers in reproductive, maternal, and newborn health (RMNH) in low-income countries remain disproportionately high. This study investigated the effectiveness of training with onsite clinical mentorship towards self-reported performance in RMNH among healthcare workers in Mwanza Region, Tanzania.MethodsThe study used a quasi-experimental design with pre-and post-intervention evaluation strategy. The baseline was compared with two endline groups: those with intervention (training and onsite mentorship) and those without. The differences among the three groups in the sociodemographic characteristics were analyzed by using chi-square test for categorical variables, independent-sample t-test for continuous variables and Mann–Whitney U test for ordinal or skewed continuous data. The independent sample t-test was used to determine the effect of the intervention by comparing the computed self-reported performance on RMNH services between the intervention and control groups. The paired-samples t-test was used to measure the differences between before and after intervention groups. Significance was set at a 95% confidence interval with p ≤ 0.05.ResultsThe study included a sample of 216 participants with before and after intervention groups comprising of 95 (44.0%) and 121 (56.0%) in the control group. The comparison between before and after intervention groups revealed a statistically significant difference (p ≤ 0.05) in all the dimensions of the self-reported performance scores. However, the comparison between intervention groups and controls indicated a statistical significant difference on intra-operative care (t = 3.10, df = 216, p = 0.002), leadership skills (t = 1.85, df = 216, p = 0.050), Comprehensive emergency obstetric and newborn care (CEMONC) (t = 34.35, df = 216, p ≤ 0.001), and overall self-reported performance in RMNH (t = 3.15, df = 216, p = 0.002).ConclusionsThis study revealed that the training and onsite clinical mentorship to have significant positive changes in self-reported performance in a wide range of RMNH services especially on intra-operative care, leadership skills and CEMONC. However, further studies with rigorous designs are warranted to evaluate the long-term effect of such training programs on RMNH outcomes.

Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.