Ethiopia Archives - Implementation Science at UW

✪ Strengthening primary care facility management: a systematic review of management interventions, implementation strategies, and outcomes in six sub-Saharan African countries

Abstract:

Background

Although primary health care (PHC) is central to health system performance, effective facility-level management is a critical determinant of service quality, resource use, and improved health outcomes. We conducted a systematic review to synthesize evidence on interventions, implementation strategies, and outcomes aimed at strengthening PHC facility management in Sub-Saharan Africa (SSA).

Methods

We conducted a systematic review using thematic synthesis. Eight electronic databases were searched for peer-reviewed studies and grey literature published between 2012 and 2022, focusing on interventions targeting PHC facility management in SSA. Implementation strategies were mapped to the thematic cluster areas of the Expert Recommendations for Implementing Change (ERIC) framework. Implementation outcomes were classified using Proctor’s Implementation Outcome Framework, and management effectiveness domains were identified through thematic analysis.

Results

Of 3,752 studies screened, nine met the inclusion criteria. These studies represented six SSA countries: Botswana, Ethiopia, Kenya, South Africa, Tanzania, and Zambia. Four categories of intervention were identified: (1) training and capacity building programs, (2) peer-to-peer learning, (3) audit and feedback-based quality management systems, and (4) supportive supervision. These interventions were delivered through multiple implementation strategies, including training and education, coaching and mentoring, learning collaboratives, interactive continuous learning, and routine data monitoring. Acceptability was the most consistently reported implementation outcome. Improvements in management effectiveness were identified across four domains: financial management, organizational climate and culture, resource management and utilization, and human resource management. Five studies also reported intermediate service-level outcomes including improvements in maternal and child health indicators.

Conclusion

Interventions aimed at strengthening PHC facility management in SSA primarily emphasize skill development, collaboration, and ongoing managerial support, typically delivered through multiple strategies. However, few studies have evaluated these interventions using rigorous experimental or pragmatic study designs. More robust implementation research is needed to identify effective strategies for strengthening PHC facility management and supporting the consistent implementation of national PHC guidelines.

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✪ A framework policy analysis of single-dose HPV vaccination adoption in East Africa: a rapid review

Abstract:

Cervical cancer is a global public health problem. While HPV vaccination effectively prevents cervical cancer, vaccination coverage remains low in low -and middle-income countries (LMICs) where around 94% of cervical cancer-related deaths occur. To improve coverage and accelerate progress toward achieving cervical cancer elimination, the World Health Organization (WHO) recommended that countries switch to a single-dose HPV vaccination schedule in 2022. Despite strong evidence of the health and economic benefits of a single-dose HPV vaccination schedule, its adoption has varied across countries.

We sought to rapidly review existing evidence to assess the “how” of policy reform on HPV vaccination, leveraging a policy analysis of single-dose HPV vaccination adoption in three East African countries. We used the Health Policy Triangle Framework (HPF) to compile key considerations that led to the adoption of single-dose HPV vaccination in Ethiopia, Uganda, and Tanzania. Relevant articles from peer-reviewed journals and grey literature published up to December 2024 were selected using pre-set inclusion and exclusion criteria. Data were extracted and summarized using a rapid qualitative analysis approach guided by the HPF. Twenty-four articles from academic and grey literature were examined.

Beyond context-specific aspects, a few common themes emerged across the three countries. Political will focused on addressing cervical cancer as a public health problem, and it was crucial to prioritize the revision of the HPV vaccination policy. The policy revision on the HPV vaccination schedule was undertaken, building on existing evidence and the WHO endorsement. Additionally, the availability of key evidence on the magnitude of this public health problem (eg: burden of the disease), the potential benefit of a single-dose schedule (efficacy, and the economic impact) played an important role in the policy revision process. At the national level, National Immunization Technical Advisory Groups (NITAGs) that provided evidence-based guidance to policy-makers were central to the single-dose decision-making process. Our findings highlighted key considerations for the policy revision process in three East African countries, which could inform strategic policy decisions in these countries and comparable settings.

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✪ Implementation research logic model in the design and execution of eHealth innovations for maternal and newborn healthcare in Ethiopia

Abstract:

Background

The use of eHealth innovations is becoming increasingly important in improving health outcomes, especially for maternal and newborn health. However, planning and executing these innovations can be challenging due to their complex nature. To provide guidance and clarity on implementation approaches, researchers need to use implementation research (IR) tools. We conducted IR to recognize the challenges in implementing eHealth innovations in the context of maternal and newborn healthcare using the implementation research logic model (IRLM). Therefore, this paper aims to describe the practical application of IRLM to design, execute and evaluate eHealth innovations that improve maternal and newborn care in public facilities in Ethiopia.

Methods

We employed rapid review, formative assessment and process evaluation of an eHealth innovation in selected healthcare facilities serving maternal and newborn care. The eHealth innovation we developed and deployed was named ‘ADHERE’ (Antenatal Care, ChilDbirtH CarE and Postnatal CaRE), representing the continuum of maternal care. The rapid review was conducted as an initial step using the Consolidated Framework for Implementation Research (CFIR). We employed a mix of data collection methods: interview/discussion, eHealth system or document review and direct observation. Furthermore, we executed various stakeholder engagement activities: two co-creation workshops and on-site iterative discussions. We applied the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) to capture ongoing implementation learnings.

Results

We developed IRLM of the eHealth innovation implementation for three contexts: urban, peri-urban and remote public healthcare facilities. The model depicted the mechanism of interaction between implementation determinants and implementation strategies to produce the intended implementation outcomes. The IRLM helped to identify more than 35 implementation barriers or facilitators for eHealth interventions and to develop over 17 mitigation strategies for the study contexts. The initial IRLM was refined through ongoing implementation learnings and the mitigation strategies that were executed.

Conclusions

The IRLM is a comprehensive and effective guiding tool for the development, implementation and evaluation of innovations in various low- and middle-income contexts. Researchers and implementing partners should adapt and use it.

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✪ Inequity in the face of success: understanding geographic and wealth-based equity in success of facility-based delivery for under-5 mortality reduction in six countries

Abstract:

Background

Between 2000–2015, many low- and middle-income countries (LMICs) implemented evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M). Even among LMICs successful in reducing U5M, this drop was unequal subnationally, with varying success in EBI implementation. Building on mixed methods multi-case studies of six LMICs (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) leading in U5M reduction, we describe geographic and wealth-based equity in facility-based delivery (FBD), a critical EBI to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries.

Methods

To obtain equity gaps in FBD coverage and changes in absolute geographic and wealth-based equity between 2000–2015, we calculated the difference between the highest and lowest FBD coverage across subnational regions and in the FBD coverage between the richest and poorest wealth quintiles. We extracted and compared contextual factors and implementation strategies associated with reduced or remaining inequities from the country case studies.

Results

The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda – decreasing from 50 to 5% across subnational regions and from 43 to 13% across wealth quintiles. The largest increases were seen in Bangladesh – from 10 to 32% across geography – and in Ethiopia – from 22 to 58% across wealth quintiles. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor (Rwanda and Peru). Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally (Bangladesh) and cultural beliefs (Ethiopia). Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs (Rwanda, Ethiopia, and Senegal) and cultural adaptation of delivery protocols (Peru). Reducing delivery costs was successful in Senegal, and partially successful in Nepal and Ethiopia.

Conclusion

Variable success in reducing inequity in FBD coverage among countries successful in reducing U5M underscores the importance of measuring not just coverage but also equity. Learning from FBD interventions shows the need to prioritize equity in access and uptake of EBIs for the poor and in remote areas by adapting the strategies to local context.

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✪ Optimising scale-up for public health impact: a multimethod implementation science research protocol to improve infant health outcomes in Ethiopia

Abstract:

Introduction

Child mortality rates remain high in sub-Saharan Africa, including Ethiopia. We are conducting a cluster randomised control trial in the Gondar zone of the Amhara region to determine the impact of pairing Orthodox priests with community health workers, known locally as the Health Development Army (HDA), on newborns’ nutritional status, early illness identification and treatment, and vaccination completeness.

Ensuring intervention efficacy with scientific rigour is essential, but there are often delays in adopting evidence into policy and programmes. Here, we present a protocol for conducting parallel implementation research alongside an efficacy study to understand intervention implementability and scalability. This will help develop a scale-up strategy for effective elements of the intervention to ensure rapid implementation at scale.

Methods and Analysis

We will conduct a stakeholder analysis of key implementation stakeholders and readiness surveys to assess their readiness to scale up the intervention. We will conduct semistructured interviews and focus group discussions with stakeholders, including HDA members, health workers, Orthodox priests, and caregivers, to determine the core intervention elements that need to be scaled, barriers and facilitators to scaling up the intervention in diverse sociocultural settings, as well as the human and technical requirements for national and regional implementation. Finally, to determine the financial resources necessary for sustaining and scaling the intervention, we will conduct activity-based costing to estimate implementation costs from the provider’s perspective.

Ethics and dissemination

The study received approval from the University of Gondar Institutional Review Board (approval no: VP/RTT/05/1030/2022) and the University of Washington Human Subjects Division (approval no: STUDY00015369). Participants will consent to participate. Results will be disseminated through workshops with stakeholders, local community meetings, presentations at local and international conferences, and journal publications. The study will provide evidence for factors to consider in developing a scale-up strategy to integrate the intervention into routine health system practices.
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✪ Monitoring and evaluating the implementation of essential packages of health services

Abstract:

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the ‘what’ and ‘for whom’ of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices.

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✪ Implementation science and stigma reduction interventions in low- and middle-income countries: A systematic review

Abstract:

Background

Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions.

Methods

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR).

Results

A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven.

Conclusion

Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.

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Implementation science for integration of HIV and non-communicable disease services in sub-Saharan Africa: a systematic review

✪ An evaluation of a common elements treatment approach for youth in Somali refugee camps

Excerpt:

Introduction

Children, defined as any boy or girl under 18 years, make up almost half of the world’s refugee population (United Nations High Commissioner for Refugees, 2016) and are exposed to challenges, traumas and stressors at the individual, family, and community levels that increase their risk for mental health problems (Barenbaum et al., 2004; Betancourt & Khan, 2008; Reed et al., 2012). These may include forced migration, forced labor, witnessing of murder and mass killings, lack of food and shelter, rape, torture, loss and separation from family, recruitment and use by armed forces, physical abuse, and family and sexual violence (Lustig et al., 2004; Office of the Special Representative of the Secretary-General for Children & Armed Conflict et al., 2009). Overlaid on potentially traumatic events are the daily, chronic stressors caused by displacement and associated with living in the camp environment – lack of basic needs, crowded and unsafe living conditions, and interpersonal conflict, among others (Layne et al., 2010; Miller & Rasmussen, 2010).

Children affected by these types of traumas and stressors present with a wide range of mental health symptoms, including those associated with posttraumatic stress (PTS), depression, anxiety, conduct problems, risk behaviors (e.g., alcohol or drug use), and distress associated with grief reactions (Barenbaum et al., 2004; Lustig et al., 2004; Sagi-Schwartz, 2008; Attanayake et al., 2009; Okello et al., 2013[for review], Morgos et al., 2008; Fernando et al., 2010; Miller & Rasmussen, 2010; Reed et al., 2012; Meyer et al., 2013; Newnham et al., 2015). Prevalence is difficult to study in these contexts; however, most studies find higher rates of mental health problems among displaced children compared with non-displaced populations (Goldstein et al., 1997; Paardekooper et al., 1999; Tousignant et al., 1999; Morgos et al., 2008; Bronstein & Montgomery, 2011; Reed et al., 2012).

There remains limited evidence on the effectiveness of interventions to treat mental health problems of children in refugee settings in low- and middle-income countries (LMICs). Some studies suggest that cognitive–behavioral-based treatments can be effective for reducing mental health symptoms in refugee children (Bolton et al., 2007; Layne et al., 2010). Relatedly, some eclectic psychosocial programs have been tested with conflict-affected populations, and show an impact on outcomes such as self-esteem or hope, but not mental health (Tol et al., 2014). Studies have generally utilized focal disorder treatments – or treatments focused on one disorder or cluster of symptoms. For example, Layne and colleagues used a treatment developed for posttraumatic stress disorder (PTSD) and grief (Layne et al., unpublished treatment manual) and Bolton and team (2007) used a treatment developed for depression (Interpersonal Therapy for depression; IPT). In contrast to this focal disorder treatment model where everyone receives the same elements in the same order, in common elements approaches providers learn elements that can be combined in different ways (elements used, order, dose) to treat a range of common mental health symptoms, and how to handle comorbidity (e.g., depression, trauma, anxiety co-occurrence) (Chorpita et al., 2005; Weisz et al., 2011; Weisz et al., 2012; Murray et al., 2014a). This approach is potentially more efficient and sustainable in both high-income countries (Mansell et al., 2008; Weisz et al., 2011; Weisz et al., 2012) and in LMICs (Bolton et al., 2014; Murray et al., 2014a; Ventevogel, 2015; Weisz et al., 2015) because it does not require providers to learn multiple interventions. Additionally, in settings with high rates of disorder comorbidity, such as in refugee populations, a model that can address multiple disorders may also be more appropriate (Murray & Jordans, 2016).

Current project

This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) (Bolton et al., 2007; Bolton et al., 2014; Murray et al., 2014a; Weisz et al., 2015) developed for comorbid presentations of depression, anxiety, post traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border; and (2) an evaluation of implementation factors including acceptability, applicability/fit, feasibility and treatment facilitators, and barriers from the perspective of staff of the implementing partner organization, lay providers, and families who engaged in…

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