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Implementation Science at UW

Keywords: Ruth Etzioni

✪ Can audit and feedback improve health service readiness and delivery outcomes in a low-resource setting? Effectiveness results of the IDEAs strategy from central Mozambique

Authors:

Aneth Dinis, Orvalho Augusto, Quinhas Fernandes, Ermyas Birru, Ruth Etzioni, Sarah Gimbel, Stephen Gloyd, Isaías Ramiro, Artur Gremu, Grace John-Stewart, Bradley H. Wagenaar, Bryan J. Weiner, Sérgio Chicumbe, & Kenneth Sherr

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: May 2025

Read the full text in the open access journal PLOS Global Public Health

Abstract:

Limited evidence exists on audit and feedback (A&F) in low-resource contexts. We tested the Integrated District Evidence-to-Action (IDEAs), a multicomponent A&F strategy in Mozambique’s maternal and child health (MCH) services. IDEAs include A&F meetings, readiness assessments, and facility support. We report the effectiveness results. IDEAs were implemented in 2016–2020 across two provinces, 12 districts, and 154 primary health facilities in Mozambique. We assessed 1) ten service delivery outcomes across antenatal, maternity, postpartum, childcare, and reproductive health services and 2) five service readiness outcomes (medicines, infrastructure, equipment, care, and staffing availability). We used propensity score matching to minimize bias and a controlled interrupted time series with a negative binomial mixed effects model for service delivery analysis, presenting incidence rate ratios (IRR) with 95% confidence intervals (95% CI). For service readiness outcomes, we created composite scores for each domain and a difference-in-difference analysis using an ordinal mixed effects model, reporting odds ratios (OR) and 95% CI. Significant associations were found with first at-risk child appointments (IRR = 1.06 [1.04, 1.07]), first polymerase chain reaction tests for HIV-exposed children (IRR = 1.02 [1.01, 1.03]), new contraceptive users (IRR = 0.95 [0.94, 0.96]), women starting long-lasting contraceptives (IRR = 0.94 [0.93, 0.95]), availability of infrastructure (OR = 5.84 [1.32, 25.88]) and essential care (OR = 0.13 [0.03, 0.54]). No significant associations were found between IDEAs and six of 10 service delivery outcomes (women with a fourth dose of preventive malaria treatment; women protected with tetanus vaccine; women with four+ antenatal visits; deliveries with active management of the third stage of labor; first postpartum consultations and fully vaccinated children) and on medicine, equipment, and staffing availability. We observed mixed effectiveness in implementing IDEAs, with null and sub-optimal effects suggesting the need to refine and adapt strategy components to more effectively address clinical and readiness outcomes.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework

Authors:

Aneth Dinis, Quinhas Fernandes, Bradley H Wagenaar, Sarah Gimbel, Bryan J Weiner, Grace John-Stewart, Ermyas Birru, Stephen Gloyd, Ruth Etzioni, Dorlim Uetela, Isaías Ramiro, Artur Gremu, Orvalho Augusto, Stélio Tembe, Jaime L Mário, Jalilo E Chinai, Alfredo F Covele, Cassimo M Sáide, Nélia Manaca & Kenneth Sherr

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2024

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes.

Methods

IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months.

Results

Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities’ first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. “Weak diagnosis or management of obstetric complications” was identified as the main problem, and “actions to reinforce norms and protocols” was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months.

Conclusion

Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**