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A Community Health System Strengthening model, which mobilizes communities by applying quality improvement, was used in 39 communities around 3 health centers in Gaza Province, Mozambique, to increase identification of pregnant women and support them to attend antenatal care (ANC). This article describes the process and results. Community group representatives formed a community improvement team to spread messages about the importance of ANC, identify pregnant women, link them to the facility, and follow up. Between March 2014 and February 2015, teams identified 2020 pregnant women. Antenatal care attendance increased at all 3 centers. One health center did an additional chart review and found that postintervention, women were enrolling in care earlier in pregnancy. There were no changes in HIV testing or treatment initiation for HIV-positive women. Community-led improvement initiatives play an important role in connecting pregnant women with services to receive testing and treatment to promote optimal health and prevent HIV transmission.
In this article, we describe the application of QI in a community setting and the accomplishments gained from that process. Quality improvement methods have been successfully adapted to community settings to improve maternal and newborn health.14-16 This intervention applied the Community Health System Strengthening model, in which an adapted QI intervention is managed by a community improvement team (CIT) composed of community groups, community health workers, facility staff, and local government officials for the purposes of identifying ways that community group members can support the community’s health goals and the local cadre of community health workers.14,17 As described in detail below, the CITs apply a QI process of setting or adopting an aim, analyzing the situation to identify problems in the process, developing change ideas that would potentially address those problems, testing small, measurable changes through plan-do-study-act cycles,18 and reviewing data regularly to determine progress toward the aim. Teams then decide whether to adopt, adapt, or discard a given change based on whether or not it resulted in improvement. Applying the Community Health System Strengthening model has been shown to improve health messaging, case identification, linkages with the formal health sector, and follow-up.14 The CIT is usually supported by coaches at the health facility and the district health management team. Licilo, Chissano, and Incaia health centers and their associated catchment areas of 15, 11, and 13 bairros, respectively, in Bilene District, Gaza Province, were selected by the Ministry of Health and the ASSIST team based on high rates of HIV prevalence and low coverage of EMTCT services. HIV prevalence in Gaza was as high as 29.9% for women and 16.8% for men in 2009.1 These 3 districts allowed for easy and low-cost access from Maputo. No other EMTCT or MCH projects were taking place in these 3 health centers at the time the activity took place. In late 2013, the ASSIST team supported Bilene District Health Office staff to orient community leaders in the bairros surrounding the Licilo, Chissano, and Incaia health centers on the objectives for the activity and the proposed approach. Following the orientation, the community leaders held discussions with the wider community about the objectives of the activity and their roles in selecting representatives to send to the initial training. Applying Science to Strengthen and Improve System and the District Health Office led a training in February 2014 for health facility staff and selected community representatives on QI, engaging community groups, and developing a data and communication process between the community and facility. The participating community representatives then met with community leaders to further explain the importance of pregnant women enrolling early in ANC, introduce the improvement aims, and what was needed from the leaders and community group members to improve care. They worked together to develop a list of active community groups, oriented these groups to the activity, and asked them to designate a representative to the CIT (or “bairro committees”). Community groups which joined the CIT included local governing structures, school parents’ associations, agricultural groups, savings and loans groups, religious groups, and street theater and other performing groups (see Figure 1). In total, 39 bairros set up CITs to support the activistas in health messaging, data collection, and follow-up. Forming a community improvement team (CIT). Each participating community group agreed to dedicate 30 minutes at their regular meetings to discuss health topics, especially the importance of early ANC. This facilitated the rapid spread of health messages to a large audience from the health-care worker to the CIT and from the CIT to their respective community groups, finally reaching households. Likewise, they set up a data collection system in which the members of the community group would bring information, such as who was pregnant in their households, and then pass it on to the CIT representative who, in turn, informed the MCH nurse from the facility who monitors whether the women have come for ANC. Community improvement teams met monthly to discuss how the community groups could assist and support the health-care workers and activistas to encourage early ANC. Each CIT reviewed simple measures, such as the number of pregnant women identified and how many of them went to their first ANC visit. They also identified and tested strategies for encouraging attendance at ANC. Community improvement teams generally met monthly and a community advisor from the project would frequently attend to provide support and facilitation (every month to 8 weeks). Maternal and child health nurses from the health centers were trained as coaches with the responsibility of helping CITs through the improvement process. As the nurses’ workload precluded participation in multiple CIT meetings each month, a health committee (high-level improvement team) was created at each health center which included the nurse coach, activistas, and representatives from each of the CITs so that delegates could participate and communicate back to the health center. The health committee also met monthly with support from the ASSIST community advisor to review progress toward the improvement aims by comparing the number of pregnant women identified by the community to the number who attended ANC at the facility. In addition, the nurse would answer questions and provide health information, which could be shared with the wider community through the improvement team members and community group structure. The health committee members also discussed possible ways that community groups could support and promote the health of pregnant women, which would be brought back to the CITs to discuss and test. District leaders, nurse coaches, and the community advisor convened learning sessions in May and August 2014. Learning sessions were workshops in which improvement teams could share their experiences and results, learn about the successes and failures of other CITs, reinforce key health messages, and discuss any challenges. The first learning session focused on mobilizing communities, encouraging participation from community groups, and setting up improvement teams in new health facility catchment areas. The second learning session focused on building QI skills, such as using data and learning rapid cycle problem-solving (plan–do–study–act cycles). In March 2015, a final meeting was convened to gather learning on how best to organize a community system to support pregnant women. Four indicators were developed to monitor progress toward achieving the improvement aims as shown in Table 1. Primary Indicators Followed by the PHFS Community Teams in Gaza Province. Abbreviations: ANC, antenatal care; PHFS, Partnership for HIV-Free Survival; Num, numerator; Den, denominator. The ASSIST community advisor supported CITs to collect data and would review the data and clarify indicators during support visits. The ANC indicator was the most challenging for teams to understand, but the advisor worked with CITs to clarify a definition (Table 1). The data on HIV testing and treatment were collected by the health facility nurse, who would report on the overall achievement for the community and not discuss individual names. No external validation of the data was conducted beyond review by the community advisor. Ethical approval or informed consent was not required. The information in this article is derived from project reports, self-reported data from the communities and facilities, and discussions conducted with health facility and community staff and volunteers for the purposes of project documentation. No individual-level patient data are presented.
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