Level of quality of option B⁺PMTCT service provision in public health facilities in Mekelle zone, northern Ethiopia: Cross-sectional study

BMC Health Services Research, Volume 20, No. 1, Year 2020

Interpretação

Background: Substantial improvements have been observed in coverage and access to maternal health services in Ethiopia. However, the quality of care has been lagging behind. Therefore, this study aimed to assess the level of quality of Option B+ PMTCT in Northern Ethiopia. Methods: A facility based survey was conducted from February to April 2016 in Northern Ethiopia. Twelve health facilities were enrolled in the study. Mixed method approach was used in line with Donabedian (Input- Process-Output) service quality assessment model. Data of 168 HIV positive mothers & their infant were abstracted from registers, and follow up charts. During the Option B+ service consultation, a total of 60 sessions were involved for direct observation. Of which, 30 clients and 12 service providers were subjected for exit and in-depth interview respectively. Facilities were categorized rendering good service quality based on predetermined quality judgment criteria. Reasons of good and bad service quality were thematically fitted with each quality component based on emerging themes (TM1-TM3), and categories (CA1-CA6). Results: Of the total 12 study health facilities, 2(16.7%) were achieved the desired level of service quality based on the three quality components. The input quality was better and judged as good in 33.3% health facilities. However; process and output service quality were realized in one – fourth of them. Conclusion: Insignificant numbers of facilities fulfilled the aspired level of service quality. Quality of care was found influenced by multiple inputs, processes, and output related barriers and facilitators. Comprehensive Program monitoring is needed based on three quality components to improve the overall service quality. The study aimed to assess the level of quality of OptionB+PMTCT and to explore reasons for good and bad service quality. This study was a facility based cross-sectional survey conducted between February to April 2016. Mixed method approach was used involving both quantitative and qualitative data collection methods. Donabedian model was used [19] as depicted in the figure below (Fig. (Fig.11). The study was conducted in Mekelle zone, Tigray of Northern Ethiopia, 802KMs from Addis Ababa, the capital city of Ethiopia. It is among the top three high HIV prevalence areas in Tigray region [22]. According to the projected national census in 2018 [23], the total population was projected to 320,000. A total of 12 health facilities have been provided Option B+ under MNCH continuum of care. Of which three of them were in hospitals. All health facilities (nine health centers and three hospitals) providing Option B+ under MNCH platforms were involved in the study. Study participants were HIV positive mother & their infants. They were newly diagnosed women and enrolled under Option B+ package aiming “test and treat” strategy. Besides, who were under continuous follow up for more than one year prior to data collection in MNCH clinic for the purpose of complete clinical history. To come up with the final sample, review of all patient records and follow up charts were conducted which fulfilled predetermined eligibility criteria. First, a total of 219 HIV positive mother & infant pairs were reviewed. However, 48 study participants were excluded since they were transferred from other facilities and did not have a complete clinical history. Similarly, three newly diagnosed HIV positive women spent only six months in HIV chronic care were not included in the study. Hence, the total participants enrolled for the study were 168. Convenience sampling method was used to recruit participants for qualitative study, until information saturation was obtained [24]. Observation and interviews were conducted during & after service consultation. A total of 60 sessions were involved for direct observation. Of which, 30 HIV positive women and 12 service providers were subjected for exit and in-depth interview respectively to identify reasons for good and bad service quality in respective quality components. Health workers have been providing Option B + PMTCT in MNCH clinic for more than one year were included in the study. Quantitative data were collected by four midwives and master’s level supervisor who had an experience in public health data collection. For input quality, 47 indicators were adopted from the national guidelines [20, 21]. Facility inventory was conducted to ensure the availability of essential equipments, drugs and supplies. See list of input quality verification variables (Additional file 1). A total of 43 process related indicators were articulated for assessing process quality [16, 17, 25]. Non-participant observation was conducted using a checklist to observe service adheres to standard practices. The intention was to observe 10 sessions from each facility during each round of data collection. However, this was not possible since too few women came for Option B+PMTCT services during the data collection period; indeed, 60 clients in which five for each facility were participated. In addition, some process related variables were obtained from recorded review. See list of process quality verification variables (Additional file 1). Output quality was assessed using 13 items adopted from national guideline [20, 21]. Data were abstracted retrospectively from logbooks and/or records and individual medical records for 168 mother infant pairs using a data abstraction tool. Besides, 12 HIV exposed infant follow up charts were reviewed about the utilization of the Option B+ service package in MNCH clinic. Confidentiality around patient records was protected; communication was made with only authorized person. Patient codes were used and documents were locked. See list of output quality verification variables (Additional file 1). Overall service quality was assessed by combining input, process, and output service quality items. Facilities were categorized rendering good input service quality, if the average weighted score of input quality performance standards is 100% [10], and 90% or more for process, output, and overall quality performance standards [10, 20]. See the score of each variable for respective quality components (Additional file 1). Qualitative data collection was guided by principal investigator (corresponding author) who had an experience on qualitative data collection. Both interviews were conducted in Tigrigna (local language), and audio recording was involved. Exit interviews were conducted with mothers who were provided oral consents for participation at the end of service consultation. After 30 interviews were involved with clients, information saturation was obtained; no further interviews were conducted since no new information was being generated. Interviews were guided by using a pre-tested flexible interview guide with probes to identify client views on service utilization. Interviews were lasted within the range of 30–40 min. In-depth interviews were held by appointment with service providers during the study. Twelve key informant interviews were conducted until information saturation was obtained. The interviews were guided by using a pre-tested, flexible interview guide with probes to identify their role in providing PMTCT services and reasons for good and bad service quality. Interviews were lasted within 15–25 min. To enhance data quality, training was provided for data collectors and supervisor with the objective of the study, the nature of the data collection tools, and ways of approaching during interview, observe, record and chart review. During the data collection period there was a strict supervision scheme. Completed questionnaires were checked on a daily basis by supervisor and principal investigator. Quantitative data were coded, cleaned, and entered into EPI info version 7 and then exported and analyzed using SPSS version 21 software. Univariate data analysis was conducted to estimate the prevalence of variables for respective quality components. The Findings were presented in tables (Tables (Tables1,1, ,2,2, ,33 and and4)4) and figure (Fig. 2). Health facilities not fulfilling 100% of input service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia (n = 12) Health facilities not fulfilling 90% of process service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia (n = 12) Health facilities not fulfilling 90% of output service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia (n = 12) Summery of themes (TMs) and categories (CAs) developed based on KIIs data in respective quality components in Mekelle zone, Tigray, Northern Ethiopia Summary of Option B + PMTCT service quality in studied health facilities in Mekelle Zone, Northern Ethiopia. [Note: (0/3): number of facilities not achieved any of the three quality components; (1/3): number of facilities achieved any one of the three quality components; (2/3): number of facilities achieved two of the three quality components; (3/3): number of facilities achieved all three quality components] Qualitative data were analyzed manually using the content thematic approach [24]. Data analysis was done by the first author in collaboration with a second author (experienced qualitative researcher). This involved reading script several times, translating transcripts from local language (Tigrigna) to English, identifying themes (TM1-TM3 …) and categories (CA1-CA6). The main study themes were fitted with three quality components, whilst categories were motivators and barriers for good and bad service quality in each identified themes. All authors were involved in discussions of study themes, & categories. This process facilitated researcher triangulation. Direct quotations were presented reflecting reasons for good and bad service quality. Input dimension: this dimension was used to assess the availability of human resources, materials, drugs, equipment, and supplies needed for Option B+ PMTCT service provision [17]. Process dimension: this dimension used to reflect how service providers adhere to service standards during a service consultation of Option B+PMTCT service in MNCH unit [18]. Output dimension: used to evaluate the ultimate service result of Option B+PMTCT service and patient satisfaction level [17]. Overall quality: this particular dimension was determined by combining predetermined three quality components; input, process, and output [25]. DBS result turnaround time: The date for DBS sample collection from HIV-exposed infants to the date when HIV screening results was arrived at health facility [26].

AI Digest

Study Justification:

– The study aimed to assess the level of quality of Option B+ PMTCT (Prevention of Mother-to-Child Transmission) services in public health facilities in Mekelle zone, northern Ethiopia.
– The study was conducted to address the lagging quality of care in maternal health services in Ethiopia, despite improvements in coverage and access.

Highlights:

– The study used a mixed method approach, combining quantitative and qualitative data collection methods.
– Data was collected from 168 HIV-positive mothers and their infants, as well as through direct observation and interviews with service providers.
– The study assessed the input, process, and output quality of Option B+ PMTCT services.
– Only 2 out of 12 health facilities achieved the desired level of service quality based on the three quality components.
– The study identified multiple barriers and facilitators influencing the quality of care.

Recommendations:

– Comprehensive program monitoring is needed based on the three quality components (input, process, and output) to improve the overall service quality.
– Interventions should be implemented to address the identified barriers and facilitators to improve the quality of Option B+ PMTCT services.

Key Role Players:

– Health facility managers and administrators
– Health workers providing Option B+ PMTCT services
– Program managers and coordinators
– Policy makers and government officials

Cost Items for Planning Recommendations:

– Training and capacity building for health workers
– Procurement of essential equipment, drugs, and supplies
– Program monitoring and evaluation activities
– Quality improvement interventions
– Communication and awareness campaigns
– Data collection and analysis tools and resources

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a facility-based cross-sectional survey conducted in Northern Ethiopia. The study used a mixed-method approach, involving both quantitative and qualitative data collection methods. The Donabedian model was used to assess the level of quality of Option B+ PMTCT service provision. The study included 12 health facilities and a total of 168 HIV positive mothers and their infants. Data was collected through abstraction of registers, follow-up charts, direct observation, and interviews. The study found that only 2 out of the 12 facilities achieved the desired level of service quality based on the three quality components. The input quality was better in 33.3% of the facilities, while process and output service quality were realized in one-fourth of them. The study concludes that there is a need for comprehensive program monitoring based on the three quality components to improve overall service quality. To improve the strength of the evidence, the study could have included a larger sample size and conducted a longitudinal study to assess changes in service quality over time. Additionally, the study could have used standardized tools for data collection and analysis to ensure consistency and comparability of results.

Resumo

The study aimed to assess the level of quality of OptionB+PMTCT and to explore reasons for good and bad service quality. This study was a facility based cross-sectional survey conducted between February to April 2016. Mixed method approach was used involving both quantitative and qualitative data collection methods. Donabedian model was used [19] as depicted in the figure below (Fig. (Fig.11). The study was conducted in Mekelle zone, Tigray of Northern Ethiopia, 802KMs from Addis Ababa, the capital city of Ethiopia. It is among the top three high HIV prevalence areas in Tigray region [22]. According to the projected national census in 2018 [23], the total population was projected to 320,000. A total of 12 health facilities have been provided Option B+ under MNCH continuum of care. Of which three of them were in hospitals. All health facilities (nine health centers and three hospitals) providing Option B+ under MNCH platforms were involved in the study. Study participants were HIV positive mother & their infants. They were newly diagnosed women and enrolled under Option B+ package aiming “test and treat” strategy. Besides, who were under continuous follow up for more than one year prior to data collection in MNCH clinic for the purpose of complete clinical history. To come up with the final sample, review of all patient records and follow up charts were conducted which fulfilled predetermined eligibility criteria. First, a total of 219 HIV positive mother & infant pairs were reviewed. However, 48 study participants were excluded since they were transferred from other facilities and did not have a complete clinical history. Similarly, three newly diagnosed HIV positive women spent only six months in HIV chronic care were not included in the study. Hence, the total participants enrolled for the study were 168. Convenience sampling method was used to recruit participants for qualitative study, until information saturation was obtained [24]. Observation and interviews were conducted during & after service consultation. A total of 60 sessions were involved for direct observation. Of which, 30 HIV positive women and 12 service providers were subjected for exit and in-depth interview respectively to identify reasons for good and bad service quality in respective quality components. Health workers have been providing Option B + PMTCT in MNCH clinic for more than one year were included in the study. Quantitative data were collected by four midwives and master’s level supervisor who had an experience in public health data collection. For input quality, 47 indicators were adopted from the national guidelines [20, 21]. Facility inventory was conducted to ensure the availability of essential equipments, drugs and supplies. See list of input quality verification variables (Additional file 1). A total of 43 process related indicators were articulated for assessing process quality [16, 17, 25]. Non-participant observation was conducted using a checklist to observe service adheres to standard practices. The intention was to observe 10 sessions from each facility during each round of data collection. However, this was not possible since too few women came for Option B+PMTCT services during the data collection period; indeed, 60 clients in which five for each facility were participated. In addition, some process related variables were obtained from recorded review. See list of process quality verification variables (Additional file 1). Output quality was assessed using 13 items adopted from national guideline [20, 21]. Data were abstracted retrospectively from logbooks and/or records and individual medical records for 168 mother infant pairs using a data abstraction tool. Besides, 12 HIV exposed infant follow up charts were reviewed about the utilization of the Option B+ service package in MNCH clinic. Confidentiality around patient records was protected; communication was made with only authorized person. Patient codes were used and documents were locked. See list of output quality verification variables (Additional file 1). Overall service quality was assessed by combining input, process, and output service quality items. Facilities were categorized rendering good input service quality, if the average weighted score of input quality performance standards is 100% [10], and 90% or more for process, output, and overall quality performance standards [10, 20]. See the score of each variable for respective quality components (Additional file 1). Qualitative data collection was guided by principal investigator (corresponding author) who had an experience on qualitative data collection. Both interviews were conducted in Tigrigna (local language), and audio recording was involved. Exit interviews were conducted with mothers who were provided oral consents for participation at the end of service consultation. After 30 interviews were involved with clients, information saturation was obtained; no further interviews were conducted since no new information was being generated. Interviews were guided by using a pre-tested flexible interview guide with probes to identify client views on service utilization. Interviews were lasted within the range of 30–40 min. In-depth interviews were held by appointment with service providers during the study. Twelve key informant interviews were conducted until information saturation was obtained. The interviews were guided by using a pre-tested, flexible interview guide with probes to identify their role in providing PMTCT services and reasons for good and bad service quality. Interviews were lasted within 15–25 min. To enhance data quality, training was provided for data collectors and supervisor with the objective of the study, the nature of the data collection tools, and ways of approaching during interview, observe, record and chart review. During the data collection period there was a strict supervision scheme. Completed questionnaires were checked on a daily basis by supervisor and principal investigator. Quantitative data were coded, cleaned, and entered into EPI info version 7 and then exported and analyzed using SPSS version 21 software. Univariate data analysis was conducted to estimate the prevalence of variables for respective quality components. The Findings were presented in tables (Tables (Tables1,1, ,2,2, ,33 and and4)4) and figure (Fig. 2). Health facilities not fulfilling 100% of input service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia (n = 12) Health facilities not fulfilling 90% of process service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia (n = 12) Health facilities not fulfilling 90% of output service quality performance verification indicators in Mekelle zone, Tigray, Northern Ethiopia (n = 12) Summery of themes (TMs) and categories (CAs) developed based on KIIs data in respective quality components in Mekelle zone, Tigray, Northern Ethiopia Summary of Option B + PMTCT service quality in studied health facilities in Mekelle Zone, Northern Ethiopia. [Note: (0/3): number of facilities not achieved any of the three quality components; (1/3): number of facilities achieved any one of the three quality components; (2/3): number of facilities achieved two of the three quality components; (3/3): number of facilities achieved all three quality components] Qualitative data were analyzed manually using the content thematic approach [24]. Data analysis was done by the first author in collaboration with a second author (experienced qualitative researcher). This involved reading script several times, translating transcripts from local language (Tigrigna) to English, identifying themes (TM1-TM3 …) and categories (CA1-CA6). The main study themes were fitted with three quality components, whilst categories were motivators and barriers for good and bad service quality in each identified themes. All authors were involved in discussions of study themes, & categories. This process facilitated researcher triangulation. Direct quotations were presented reflecting reasons for good and bad service quality. Input dimension: this dimension was used to assess the availability of human resources, materials, drugs, equipment, and supplies needed for Option B+ PMTCT service provision [17]. Process dimension: this dimension used to reflect how service providers adhere to service standards during a service consultation of Option B+PMTCT service in MNCH unit [18]. Output dimension: used to evaluate the ultimate service result of Option B+PMTCT service and patient satisfaction level [17]. Overall quality: this particular dimension was determined by combining predetermined three quality components; input, process, and output [25]. DBS result turnaround time: The date for DBS sample collection from HIV-exposed infants to the date when HIV screening results was arrived at health facility [26].

Materiais

https://efashare.b-cdn.net/materials/b2db1d365aba43c509836b7e9a4e7201c74c9cd72a616ef6452abf7c4ec768b4/12913_2020_5429_MOESM1_ESM.xls

Inovações

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can improve access to maternal health by allowing pregnant women to consult with healthcare providers remotely. This can be particularly beneficial for women in rural or remote areas who may have limited access to healthcare facilities.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources related to maternal health can help women access important healthcare information and services. These apps can provide prenatal care tips, appointment reminders, and educational materials.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services and education in underserved areas can improve access to care. These workers can conduct prenatal visits, provide health education, and refer women to appropriate healthcare facilities when needed.

4. Transportation services: Establishing transportation services specifically for pregnant women can help overcome barriers related to distance and transportation. This can include providing free or subsidized transportation to healthcare facilities for prenatal visits and delivery.

5. Mobile clinics: Setting up mobile clinics that travel to remote or underserved areas can bring essential maternal health services directly to women who may have difficulty accessing traditional healthcare facilities.

6. Public-private partnerships: Collaborating with private healthcare providers and organizations can help expand access to maternal health services. This can involve partnering with private hospitals or clinics to provide services at reduced costs or offering incentives for private providers to offer maternal health services in underserved areas.

7. Health education campaigns: Implementing targeted health education campaigns to raise awareness about the importance of maternal health and available services can help increase utilization of maternal health services. These campaigns can be conducted through various channels, such as radio, television, social media, and community outreach programs.

8. Strengthening referral systems: Improving the coordination and communication between different levels of healthcare facilities can ensure that pregnant women are referred to appropriate facilities for specialized care when needed. This can help prevent delays in accessing necessary maternal health services.

It is important to note that the specific recommendations for improving access to maternal health may vary depending on the local context and resources available.

AI Innovations Description

The study mentioned aims to assess the level of quality of Option B+ PMTCT (Prevention of Mother-to-Child Transmission) services in public health facilities in Mekelle zone, northern Ethiopia. The study used a mixed-method approach, including quantitative and qualitative data collection methods. The Donabedian model, which includes input, process, and output dimensions, was used to assess service quality.

The study was conducted in 12 health facilities in Mekelle zone, which provide Option B+ PMTCT services. The participants were HIV-positive mothers and their infants who were newly diagnosed and enrolled under the Option B+ package. Data were collected through record reviews, observations, and interviews with both clients and service providers.

The study found that only a small number of facilities achieved the desired level of service quality. The input quality, which assesses the availability of resources and materials, was better in one-third of the facilities. However, the process and output service quality were realized in only one-fourth of the facilities. The study identified multiple barriers and facilitators that influenced the quality of care.

Based on the findings of this study, a recommendation to improve access to maternal health would be to focus on improving the quality of Option B+ PMTCT services in public health facilities. This could be achieved by addressing the identified barriers and facilitators and implementing comprehensive program monitoring based on the three quality components (input, process, and output). By ensuring the availability of necessary resources, adherence to service standards, and satisfactory service results, the overall service quality can be improved, leading to better access to maternal health services.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening Health Facility Infrastructure: Ensure that health facilities have adequate infrastructure, including well-equipped labor and delivery rooms, clean and comfortable waiting areas, and sufficient space for antenatal and postnatal care services.

2. Enhancing Human Resources: Increase the number of skilled healthcare providers, such as midwives and obstetricians, to ensure that there are enough personnel to provide quality maternal health services. This may involve training and recruiting more healthcare professionals, as well as improving retention strategies.

3. Improving Availability of Essential Supplies and Medications: Ensure that health facilities have a consistent supply of essential medical equipment, drugs, and supplies needed for maternal health services. This can be achieved through effective supply chain management and regular monitoring of stock levels.

4. Strengthening Referral Systems: Develop and implement effective referral systems to ensure that pregnant women can access higher-level care when needed. This may involve establishing clear protocols for referral, improving communication between different levels of healthcare facilities, and providing transportation support for women who need to be transferred.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations on access to maternal health. For example, indicators could include the number of women receiving antenatal care, the percentage of women delivering in healthcare facilities, or the average distance traveled to access maternal health services.

2. Collect baseline data: Gather data on the current status of access to maternal health services, including the selected indicators. This can be done through surveys, interviews, or analysis of existing data sources.

3. Implement the recommendations: Introduce the recommended interventions or improvements in the selected areas, such as infrastructure, human resources, supplies, and referral systems.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through regular data collection, surveys, or interviews with healthcare providers and service users.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on access to maternal health services. Compare the baseline data with the post-intervention data to identify any changes or improvements.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health services. Identify any gaps or areas for further improvement and make recommendations for future interventions.

7. Repeat the process: Continuously repeat the monitoring and evaluation process to assess the long-term impact of the recommendations and make any necessary adjustments or additional interventions.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further interventions.

Autor

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1186/s12913-020-05429-6

Research Areas:

Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Ethnographic Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative, Systematic Review

Participants Gender:

Female

Partilhar isto:

Level of quality of option B+PMTCT service provision in public health facilities in Mekelle zone, northern Ethiopia: Cross-sectional study

Level of quality of option B⁺PMTCT service provision in public health facilities in Mekelle zone, northern Ethiopia: Cross-sectional study