1. Respectful Maternity Care implementation research in Tanzania: The Staha Project GWU Miliken School of Public Health June 24, 2014

2. AIM: REDUCE D&A medicine and supplies stockouts community doesn’t know their rights health workers don’t know their rights distrust between providers and clients health worker burnout & demotivation lack of safe channels to report D&A organizational culture in the health system provocation by relatives modeling of D&A behaviours in training unfair processes in the health system weak accountability POWER DYNAMICS discrepancy between policy promises and reality lack of recognition for good performance infrastructure weaknesses workforce shortages stress of maternity assignment ethics

3. Pre-intervention qualitative data: Patient-provider interactions Misunderstandings about what is the health workers’ fault and what is due to system constraints Community distrust health workers, think that they steal medicines and sell in their own pharmacies Health providers distrust community, think that they don’t understand what actually happened/are ignorant Good interactions exist outside the work environment (as neighbors or at social events), but changes at facility Nurses are typically blamed Neither patients nor providers feel that they know their rights

4. Values driven process: Mutuality of respect Patients Respectful Health System Environment Providers RESPECT

5. Participatory planning Preliminary results, identification of root causes, brainstorm solutions Stakeholders across levels: National Regional District Facility Community Propose and review potential solutions Community members Village and ward leaders Health workers in the maternity District and facility management Represent -atives from local groups Community members Health workers in the maternity

6. Staha Change Process Client Service Charter – Adapt the national charter in a participatory process at district and health facility level to elaborate the value of mutual respect Facility-based quality improvement – maternity teams address issues related to mutual respect and devise ways to implement and measure change Community and health system management actions – Communities implement and monitor activities to support providers and ensure accountability – District leaders and managers change practices to support an environment of respect and attention for providers and patients

7. District and facility management policy and practice changes Facility- based QI process to change environment/ practice Community- driven actions to support and monitor system District- level adaptation of charter Facility- level adaptation of charter Norms and standards of mutual respect Increased mutual respect Consensus building on norms and standards Multi-level activation of mutual respect norms Improved outcomes Increased facility-based delivery Reduced D&A during childbirth Increased facility-based delivery Reduced D&A during childbirth STAHA CHANGE PROCESS

8. Implementation research: data collection methods CharterQI process Qualitative interviews/FGDsMaternity exit survey Drafting meeting minutesProvider weekly survey Participant observationWeekly observation Charter feedback formsCollective efficacy survey Dissemination/activity monitoring forms* QI team weekly meeting minutes Qualitative interviews/FGDs

9. Implementation research strategy Based on: – Damschroder et al’s Consolidated Framework for Advancing Implementation Science (CFIR) – Carroll et al’s Framework for Implementation Fidelity Overall goal of studying and uncovering the process of the implementation under key domains: – Moderators of change – Support mechanisms – Context and inner/outer settings – Fidelity

10. Intervention components

11. Client Service Charter National charter developed in 2005, never adapted at district levels Korogwe is the first district to adapt charter to reflect local needs and concerns District charter developed first, followed by facility- specific charters Mechanism to open dialogue between different levels of district health system and communities

12. Steps in local charter adaptation At district & facility levels: Select charter committee Review MoHSW/existing charter Develop new draft of charter Solicit feedback from multiple stakeholders through comment forms & community meetings Integrate comments in charter Seek approval by District Council Disseminate, implement & monitor Make revisions as needed

13. Frequent Comments on Draft More transparency of fees and services Services should be provided in a timely manner Make providers’ rights more specific Facilities should be a corruption-free environment Use respectful language when speaking to patients

14. Key messages in the charter Mutuality of respect Patient rights & responsibilities Provider rights & responsibilities Standards of service, including relationships Standards of ethical conduct Accountability, feedback and complaint mechanisms Equality and respect for all Ongoing maintenance of charter

15. Dissemination and Activation Materials developed to support dissemination – Printed copies of charters – Summaries of key provider and patient rights and responsibilities – Posters Meetings with key leaders at district, health facility and community levels – Training on dissemination of charter – Plans and commitments for charter activation

16. Quality Improvement Process Views disrespect and abuse as a systemic problem rather than an individual or behavioral problem Applies a clinical quality improvement framework to an interpersonal quality of care issue (adapts Institute of Healthcare Improvement framework)

17. Intervention launch at Magunga Hospital, Korogwe District 2-day workshop to introduce QI to the maternity ward and key personnel from RCH, theatre, and pharmacy Staff identified drivers of D&A and proposed specific interventions for change 6 people chosen by their peers as the QI team: – 1 doctor from the maternity ward – 2 nurses from the maternity ward – 1 pharmacist – 1 nurse from RCH – 1 nurse from theatre The regional MOH QI specialist and the deputy medical officer in charge at the hospital supervised the team

18. Quality Improvement Interventions Move admission and discharge to a private room Obtain/use curtains in the delivery room and screens in the maternity for privacy Pharmacy creates a stock out list each week to post in the maternity ward Recognize providers with tea, certificates, etc. Peer-to-peer learning with Bombo Hospital QI Team

19. QI Intervention: Implementation research Self-reported exit survey of all postpartum women on quality of care and satisfaction with interaction with providers Provider knowledge Language use Provider communication Provider responsiveness Overall quality of care Respect Privacy Availability of drugs and supplies Ward cleanliness

20. Patient surveys: analysis N = 1720, 43 weeks of data from August 2013-April 2014 (ongoing) Two weeks of baseline data collection Data divided into pre-post intervention at week 19 – All interventions implemented by week 15 – At week 19, providers started to use a checklist per patient to ensure that interventions were followed

21. Patient surveys: logistic regression analysis Outcome categorized as excellent vs. other categories Main predictor: pre/post 19 weeks Controlled for age and clustered on date

22. Patient surveys: results to questions (%) ExcellentGoodFairPoor Overall quality of care 70.0127.242.580.18 Respect 70.3027.831.760.12 Privacy 68.1328.663.220.06 Language use 65.3331.553.060.06 Provider communication 66.8631.071.830.24 Availability of supplies 70.3526.132.940.59 Provider knowledge 73.7224.102.060.12 Ward cleanliness 65.4430.993.040.53

23. Patient surveys: results to questions by time period (%) < 19 weeks≥ 19 weeks ExcellentGoodFairPoorExcellentGoodFairPoor Overall quality of care 63.3432.693.690.2775.0023.161.740.10 Respect 61.3935.612.730.2777.0021.971.030.10 Privacy 62.7932.284.790.1472.1325.921.950.00 Language use 58.0737.244.550.1470.7327.331.940.00 Provider communication 60.6436.582.230.5671.4427.021.540.00 Availability of supplies 62.1732.874.260.6976.4321.111.950.51 Provider knowledge 70.6627.271.790.2876.0021.742.260.00 Ward cleanliness 58.4537.603.270.6870.7026.022.870.41

24. Overall quality of care Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

25. Respect Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

26. Privacy Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

27. Provider language Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

28. Provider communication Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

29. Availability of supplies Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

30. Provider knowledge Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

31. Ward cleanliness Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

32. Other events in maternity ward: example – overall quality of care Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions Week 18: nursing students start Weeks 27-29: staff shortage Week 24: nurse changes

33. Patient surveys: regression results OutcomeOdds Ratio 95% CI Overall quality of care1.59***1.20-2.13 Respect1.95***1.47-2.58 Privacy1.40*1.08-1.82 Language use1.61***1.24-2.09 Provider communication1.45**1.12-1.87 Availability of supplies1.93***1.45-2.56 Provider knowledge1.160.87-1.54 Ward cleanliness1.45**1.10-1.91 P-value: *<0.05, **<0.01, ***<0.001

34. Challenges to implementation Interventions that require funds or approval by hospital management can take longer to implement Maternity ward staff who did not attend the QI training were less able to explain the process and its importance Documentation/monitoring of interventions can be difficult due to poor record-keeping at the maternity ward Some women express concern when using moveable screens in the maternity ward that being covered during examination implies serious illness

35. Limitations of findings Preliminary results not adjusted for time trends Trend could be due to something other than intervention (ex: availability of supplies) Positivity effect: women could be rating everything as positive overall Women have changed over time? No comparison group

36. Implications for future Staha research End line survey to see if intervention is having an effect on D&A

37. Thank you

38. Moderators of change: key questions How have key stakeholders contributed to the implementation/intervention? How did participants of the intervention react to and accept the intervention? How has the perception of disrespect and abuse changed over time? What is the role of the health providers’ collective efficacy in facilitating change? How have the power dynamics between patients and providers changed?

39. Moderators of change: data components Charter process: – Personal narration by charter facilitator – In-depth interviews with key stakeholders – Participant observations QI process: – In-depth interviews with key stakeholders – FGDs with health providers – Patient exit survey – Provider survey – Provider collective efficacy survey

40. Support mechanisms Key question: – To what extent did the Staha team itself affect the outcome of the intervention? For example, what occurred/may not have occurred without the support and facilitation of the implementers/researchers? Data component: – Project documents – Qualitative interviews

41. Fidelity Key questions: – To what extent is the intervention being implemented as intended? – What were the challenges to implementation? What elements of the intervention were adapted during the implementation in order to react to the realities on the ground? Data components: – Project documents, meeting minutes – Qualitative interviews with key stakeholders and participants – Observations

42. Context: inner/outer settings Key question: – How do the social, economic, structural, and political factors of the intervention district, including of the targeted intervention community and of the health facilities, affect the implementation and the intervention outcome? Data components: – Qualitative interviews with key stakeholders – Landscape scanning

43. Charter Process: Preliminary lessons Charter committee representation from district government and health system and community D&A in childbirth as lens onto broader quality issues – touches on many encounters with the health system Building consensus – Allow space for airing contentious issues – Gradual consensus building from disparate perspectives System insiders open to new possibilities; recognize value of community perspectives Community representatives made aware of structural/capacity limitations; recognize their own power to make change Local government leaders start recognize their role in ensuring quality of health services for their populations