Sarah Gimbel Archives - Page 3 of 3 - Implementation Science at UW

✪ Implementation strategy and cost of Mozambique’s HPV vaccine demonstration project

Abstract:

Background

Cost is an important determinant of health program implementation. In this study, we conducted a comprehensive evaluation of the implementation strategy of Mozambique’s school-based HPV vaccine demonstration project. We sought to estimate the total costs for the program, cost per fully immunized girl (FIG), and compute projections for the total cost of implementing a similar national level vaccination program.

Methods

We collected primary data through document review, participatory observation, and key informant interviews at all levels of the national health system and Ministry of Education. We used a combination of micro-costing methods—identification and measurement of resource quantities and valuation by application of unit costs, and gross costing—for consideration of resource bundles as they apply to the number of vaccinated girls. We extrapolated the cost per FIG to the HPV-vaccine-eligible population of Mozambique, to demonstrate the projected total annual cost for two scenarios of a similarly executed HPV vaccine program.

Results

The total cost of the Mozambique HPV vaccine demonstration project was $523,602. The mean cost per FIG was $72 (Credibility Intervals (CI): $62 - $83) in year one, $38 (CI: $37 - $40) in year two, and $54 CI: $49 - $61) for years one and two. The mean cost per FIG with the third HPV vaccine dose excluded from consideration was $60 (CI: $50 - $72) in year one, $38 (CI: $31 - $46) in year two, and $48 (CI: $42 - $55) for years one and two. The mean cost per FIG when only one HPV vaccine dose is considered was $30 (CI: $27 - $33)) in year one, $19 (CI: $15–$23) in year two, and $24 (CI: $22–$27) for both years. The projected annual cost of a two-and one-dose vaccine program targeting all 10-year-old girls in the country was $18.2 m (CI: $15.9 m - $20.7 m) and $9 m (CI: $8 m - $10 m) respectively.

Conclusion

National adaptation and scale-up of Mozambique’s school-based HPV vaccine strategy may result in substantial costs depending on dosing. For sustainability, stakeholders will need to negotiate vaccine price and achieve higher efficiency in startup activities and demand creation.

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

✪ Development and Implementation of a Mobile Phone–Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility Testing in Kenya and Mozambique

Abstract:

Background

Prevention of mother-to-child HIV transmission (PMTCT) care cascade failures drive pediatric HIV infections in sub-Saharan Africa. As nurses’ clinical and management role in PMTCT expand, decision-support tools for nurses are needed to facilitate identification of cascade inefficiencies and solutions. The mobile phone–based PMTCT cascade analysis tool (mPCAT) provides health facility staff a quick summary of the number of patients and percentage drop-off at each step of the PMCTC care cascade, as well as how many women-infant pairs would be retained if a step was optimized.

Objective

The objective of this study was to understand and improve the mPCAT’s core usability factors and assess the health workers’ experience with using the mPCAT.

Methods

Overall, 2 rounds of usability testing were conducted with health workers from 4 clinics and leading experts in maternal and child health in Kenya and Mozambique using videotaped think aloud assessment techniques. Semistructured group interviews gauged the understanding of mPCAT’s core usability factors, based on the Nielsen Usability Framework, followed by development of cognitive demand tables describing the needed mPCAT updates. Post adaptation, feasibility was assessed in 3 high volume clinics over 12 weeks. Participants completed a 5-point Likert questionnaire designed to measure ease of use, convenience of integration into work, and future intention to use the mPCAT. Focus group discussions with nurse participants at each facility and in-depth interviews with nurse managers were also conducted to assess the acceptability, use, and recommendations for adaptations of the mPCAT.

Results

Usability testing with software engineers enabled real-time feedback to build a tool following empathic design principles. The revised mPCAT had improved navigation and simplified data entry interface, with only 1 data entry field per page. Improvements to the results page included a data visualization feature and the ability to share results through WhatsApp. Coding was simplified to enable future revisions by nontechnical staff—critical for context-specific adaptations for scale-up. Health care workers and facility managers found the tool easy to use (mean=4.3), used the tool very often (mean=4.1), and definitely intended to continue to use the tool (mean=4.8). Ease of use was the most common theme identified, with emphasis on how the tool readily informed system improvement decision making.

Conclusions

The mPCAT was well accepted by frontline health workers and facility managers. The collaborative process between software developer and user led to the development of a more user-friendly, context-specific tool that could be easily integrated into routine clinical practice and workflow. The mPCAT gave frontline health workers and facility managers an immediate, direct, and tangible way to use their clinical documentation and routinely reported data for decision making for their own clinical practice and facility-level improvements.

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

✪ Scaling-up the Systems Analysis and Improvement Approach for prevention of mother-to-child HIV transmission in Mozambique (SAIA-SCALE): a stepped-wedge cluster randomized trial

Abstract:

Background

The introduction of option B+ — rapid initiation of lifelong antiretroviral therapy regardless of disease status for HIV-infected pregnant and breastfeeding women — can dramatically reduce HIV transmission during pregnancy, birth, and breastfeeding. Despite significant investments to scale-up Option B+, results have been mixed, with high rates of loss to follow-up, sub-optimal viral suppression, continued pediatric HIV transmission, and HIV-associated maternal morbidity. The Systems Analysis and Improvement Approach (SAIA) cluster randomized trial demonstrated that a package of systems engineering tools improved flow through the prevention of mother-to-child HIV transmission (PMTCT) cascade. This five-step, facility-level intervention is designed to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). This protocol describes a novel model for SAIA delivery (SAIA-SCALE) led by district nurse supervisors (rather than research nurses), and evaluation procedures, to serve as a foundation for national scale-up.

Methods

The SAIA-SCALE stepped wedge trial includes three implementation waves, each 12 months in duration. Districts are the unit of assignment, with four districts randomly assigned per wave, covering all 12 districts in Manica province, Mozambique. In each district, the three highest volume health facilities will receive the SAIA-SCALE intervention (totaling 36 intervention facilities). The RE-AIM framework will guide SAIA-SCALE’s evaluation. Reach describes the proportion of clinics and population in Manica province reached, and sub-groups not reached. Effectiveness assesses impact on PMTCT process measures and patient-level outcomes. Adoption describes the proportion of districts/clinics adopting SAIA-SCALE, and determinants of adoption using the Organizational Readiness for Implementing Change (ORIC) tool. Implementation will identify SAIA-SCALE core elements and determinants of successful implementation using the Consolidated Framework for Implementation Research (CFIR). Maintenance describes the proportion of districts sustaining the intervention. We will also estimate the budget and program impact from the payer perspective for national scale-up.

Discussion

SAIA packages user-friendly systems engineering tools to guide decision-making by frontline health workers, and to identify low-cost, contextually appropriate PMTCT improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial is designed to test a model for national intervention scale-up.

Trial Registration

ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

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

✪ Human papillomavirus vaccine delivery in Mozambique: Identification of implementation performance drivers using the Consolidated Framework for Implementation Research (CFIR)

Abstract:

Background

Since 2012 Gavi, the Vaccine Alliance has provided financial support for HPV vaccine introduction in low- and middle-income countries (LMICs); however, funding has been contingent on establishing a demonstration project prior to national scale-up, in order to gauge effectiveness of delivery models. Although by 2016, most beneficiary countries had completed demonstration projects, few have scaled up delivery nationwide. An important barrier was the dearth of published, country-specific implementation recommendations. We employed the Consolidated Framework for Implementation Research (CFIR) as a lens to identify drivers of heterogeneous (dissimilar) implementation performance during Mozambique’s 2-year demonstration project. Mozambique presents a compelling example as the country conducted demonstration projects in three different districts with extremely different economic resources and sociocultural practices.

Methods

A post implementation interpretive evaluation was undertaken. Forty key informant interviews were conducted with district and health facility immunization staff, Ministry of Education managers, and teachers across the three demonstration districts, central level informants from MOH, research institutes, and immunization program partners. We compared valence and strength ratings of CFIR constructs, across diverse implementation sites, so as to explain drivers and barriers to implementation success. Two researchers coded separately, and subsequent content analysis followed pre-defined CFIR construct themes.

Results

Eighteen constructs emerged from informants’ responses as implementation influencers. Adaptability was identified as an important construct because delivery modalities needed to meet differing levels of girls’ school attendance. Expanding outside of school-based delivery was needed in the low-performing district, making the vaccine delivery process more complex. Available resources varied across the three sites, with one site receiving direct Gavi support, while others received primarily state-based support. These latter sites reported considerably more implementation bottlenecks, in part related to weaker infrastructural characteristics and insufficient organizational incentives. Health workers’ beliefs in importance of vaccines and an organizational culture of making personal sacrifice for immunization program activities drove implementation performance. Advocacy and social mobilization through the right opinion leaders and champions generated higher demand.

Conclusion

HPV vaccination presents a pertinent opportunity for the prevention of cervical cancer in Mozambique, sub-Saharan Africa, and other LMICs. However, important barriers to broad-scale implementation exist. We recommend the development of local and global strategies to overcome barriers and facilitate its expanded utilization.

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

✪ Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries

Abstract:

Background

Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation’s (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions.

Methods

We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia.

Results

Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private) are necessary to address complex health system issues at all levels. Second, a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Third, inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Fourth, five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects.

Conclusion

The AHI experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.

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

✪ Improving data quality across 3 sub-Saharan African countries using the Consolidated Framework for Implementation Research (CFIR): results from the African Health Initiative

Abstract:

Background

High-quality data are critical to inform, monitor and manage health programs. Over the seven-year African Health Initiative of the Doris Duke Charitable Foundation, three of the five Population Health Implementation and Training (PHIT) partnership projects in Mozambique, Rwanda, and Zambia introduced strategies to improve the quality and evaluation of routinely-collected data at the primary health care level, and stimulate its use in evidence-based decision-making. Using the Consolidated Framework for Implementation Research (CFIR) as a guide, this paper: 1) describes and categorizes data quality assessment and improvement activities of the projects, and 2) identifies core intervention components and implementation strategy adaptations introduced to improve data quality in each setting.

Methods

The CFIR was adapted through a qualitative theme reduction process involving discussions with key informants from each project, who identified two domains and ten constructs most relevant to the study aim of describing and comparing each country’s data quality assessment approach and implementation process. Data were collected on each project’s data quality improvement strategies, activities implemented, and results via a semi-structured questionnaire with closed and open-ended items administered to health management information systems leads in each country, with complementary data abstraction from project reports.

Results

Across the three projects, intervention components that aligned with user priorities and government systems were perceived to be relatively advantageous, and more readily adapted and adopted. Activities that both assessed and improved data quality (including data quality assessments, mentorship and supportive supervision, establishment and/or strengthening of electronic medical record systems), received higher ranking scores from respondents.

Conclusion

Our findings suggest that, at a minimum, successful data quality improvement efforts should include routine audits linked to ongoing, on-the-job mentoring at the point of service. This pairing of interventions engages health workers in data collection, cleaning, and analysis of real-world data, and thus provides important skills building with on-site mentoring. The effect of these core components is strengthened by performance review meetings that unify multiple health system levels (provincial, district, facility, and community) to assess data quality, highlight areas of weakness, and plan improvements.

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

Health facility factors and quality of services to prevent mother-to-child HIV transmission in Côte d’Ivoire, Kenya, and Mozambique

✪ Evaluation of a Systems Analysis and Improvement Approach to Optimize Prevention of Mother-To-Child Transmission of HIV Using the Consolidated Framework for Implementation Research

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Read the full text in the subscription access International Journal of STD & AIDS

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