Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda

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Study Justification:
– High maternal and neonatal mortality rates in Uganda
– Need to harness community capacities and resources to complement supply side initiatives
– Participatory action research approach to improve maternal and newborn health in rural Uganda
Highlights:
– Increased awareness about birth preparedness, improved newborn care practices, and male involvement in maternal and newborn health
– Strengthening of saving groups and other saving modalities to meet transport costs and purchase necessary items
– Improved linkages between savings groups and transport providers for better access to health facilities
– Key role of village health teams in providing information, but constrained by low education levels, inadequate compensation, and transportation challenges
– Regular supervision, review meetings, and payment for supervisors needed to ensure functioning of village health teams and savings groups
Recommendations:
– Develop additional direct communication strategies to reach more men beyond those who attended community dialogues and home visits
– Provide significant support to saving groups to improve income generation, management, and trust among members
– Address education, compensation, and transportation challenges faced by village health teams
– Ensure regular supervision, review meetings, and payment for supervisors to support village health teams and savings groups
Key Role Players:
– Community leaders (local council leaders, religious leaders)
– District stakeholders (administrative and technical system, district health teams)
– Makerere University School of Public Health research team (health systems experts, obstetricians, pediatricians, statisticians, sociologists, microfinance specialists)
– Community development officers
– Village health teams
Cost Items for Planning Recommendations:
– Additional communication strategies development
– Support for saving groups (income generation, management, trust building)
– Education, compensation, and transportation support for village health teams
– Regular supervision and review meetings
– Payment for supervisors’ visits

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a participatory action research project conducted in rural Uganda. The abstract provides information on the methods used, the results obtained, and the conclusions drawn from the project. However, the abstract does not provide specific details on the sample size, data collection methods, or statistical analysis. To improve the strength of the evidence, the abstract could include more information on these aspects, as well as any limitations of the study. Additionally, providing references to the full publication would allow readers to access more detailed information about the study.

Background: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. Methods: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Results: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women’s access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. Conclusions: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.

Our work is situated in rural eastern Uganda, with a total estimated population of 1,045,100, consisting of Kamuli district (population 500,800), Pallisa district (362,600), and Kibuku district (181,700). Kibuku was carved out of Pallisa in 2010 and the two districts share similar economic activities, mainly crop farming and animal husbandry. Kamuli has more diverse economic activities, which include crop farming, animal husbandry, ranching, fishing, fish farming, bee keeping, quarrying and retail trading. The participatory action research approach was facilitated by a project called MANIFEST (Maternal and Neonatal Implementation for Equitable Systems), which aimed at improving maternal and neonatal health. It was implemented from 2013 to 2015, following a 9 month design phase in 2012 and based on prior working relationships between key partners starting in 2009. The main goal of the project was to improve maternal and newborn health by increasing community awareness, action and access to maternal and neonatal health (MNH) services. MANIFEST was implemented by district stakeholders with technical support provided by a Makerere University School of Public Health (MAKSPH) research team. District stakeholders involved actors at the community, parish, sub-county, and district levels. These stakeholders included leaders from the political system (local council leaders), administrative and technical system, community/religious system (priests and imams), and the district health system (from village level community health volunteers to district health teams) (Table 1). The MAKSPH team comprised of a multidisciplinary group of researchers and specialists including health systems experts, obstetricians, paediatricians, statisticians, sociologists and micro finance specialists. MANIFEST stakeholders from community to district levels PAR involves diagnosing a problem, planning action to address the problem, taking action and learning from this action in a cyclical manner. These stages are detailed in the sections that follow. It is important to include all stakeholders (especially the end users, i.e. households) in the design stage, to ensure that the solutions developed align with stakeholder needs and contexts. We conducted a series of consultation workshops and focus group discussions with community members to identify problems that women face when seeking maternal health services and to identify feasible solutions to these problems. These discussions were held along three main themes: quality of maternal health services, birth preparedness and transport for maternal health. The findings from these consultations were used to develop key components of the interventions implemented. Following the design stage, implementation manuals and training materials were developed by MAKSPH and district based staff. These manuals and training materials were designed to be used by different implementing actors while conducting community dialogues, home visits and radio talk shows and while managing saving groups. The project strengthened the capability of community stakeholders through community mobilization and supportive mechanisms (Fig. 1). Project framework mapping community capability to improved maternal and newborn health Community mobilization involved improving awareness about maternal and newborn health and improving maternal and newborn health practices in the home, specifically promoting birth preparedness; appropriate home care for pregnant women and newborns, and supportive male involvement. Awareness was raised through VHT home visits, community dialogues, talk shows, and radio spots. The radio sports covered a wide range of topics including: the importance of attending antenatal care, delivering in a facility, and receiving postnatal care; encouraging male involvement in maternal health; birth preparedness; the benefits of saving money to enable healthcare spending during pregnancy, childbirth and the neonatal period; and newborn danger signs, referral and caring for newborns. The radio spots and messages, developed in conjunction with the district health educator based on feedback from the design phase, were aired on local radio stations in respective local languages. The spots were run daily and the talk shows were conducted on a monthly basis. The talk shows were delivered by the district health officials and political leaders. Concurrently, support was provided for community development officers (public servants responsible for community development work including providing support to saving groups) and VHTs (community health workers). This support consisted of skills based training on how to assist saving groups in improving their management, their abilities to generate income and their link with local transport providers. A refresher training was conducted at the beginning of the project followed by quarterly meetings that were used to reinforce knowledge (Table 2). Types of review meetings In addition, quarterly supportive supervision of VHTs and quarterly review meetings at both sub county and district levels were supported to both build capacity and strengthen local accountability. As shown in Table ​Table2,2, during these meetings government actors (VHTs, community development officers, health assistants, sub county and district managers) were asked by local stakeholders (politicians, religious representatives, development partners, and local council leaders) to explain cases of poor service delivery in their respective areas. The government actors were informed about these cases through their community activities such as home visits and community dialogues. Solutions to these problems were then discussed and agreed upon. The MAKSPH research team and the district teams documented these meetings, noting issues discussed, achievements and challenges. General findings and learning events from the project were identified and documented on an ongoing basis. This included how planned activities were carried out, challenges experienced, how these challenges were resolved, and whether the objectives of the meetings or activities were met. The implementation of the program was undertaken in a phased manner to ensure learning from the roll out of the program. There was engagement with stakeholders at all levels to share experiences and lessons learned during the action cycle. The review meetings (Table 2) allowed all those involved in implementation as well as recipients to explore their subjective experiences about the programme, actions taken, as well as mechanisms and reasons for these actions. This continuous assessment helped to inform decisions to improve outcomes of the programme and to increase chances for sustaining the initiatives. Stakeholders identified problems and suggested solutions; the program was then adjusted based on these suggestions. Table 3 provides a summary of key changes that were made and reasons for these changes. Key changes made to the programme and reasons for the changes Alongside the PAR intervention, MaKSPH undertook a series of research activities designed to evaluate and inform the project. All study procedures were documented, as well as any deviations or changes that were made, in addition to any intended and unintended positive and negative consequences and steps taken to mitigate negative consequences. In addition, data for this paper has been drawn from key informant interviews (KIIs) and focus group discussions (FGDs). Twenty KIIs were carried out across the three districts with members of the sub county implementation committee who were involved in the implementation of the project at the beginning of the study and at the end of it, e.g. sub county chiefs, chairpersons, religious leaders, health assistants and facility in-charges. KIIs were also conducted with community leaders who were mainly involved in community mobilisation, such as local council chairmen and VHTs. In addition, KIIs were done with members of the district health team who took the lead in overseeing implementation. Written informed consent was sought from the key informants before conducting the interviews. Furthermore, 12 FGDs across the three districts were carried out at the beginning and end of the project. The FGDs were homogenous in composition and were with women (6 FGDs) of reproductive age who had given birth during the project’s implementation and men (6 FGDs) whose wives had delivered during the same period. Each of these FGDs consisted of eight to 12 participants. The participants for the focus group discussions were chosen purposively with the help of the local council one chairpersons who are the gatekeepers in the community. Verbal informed consent was sought from the focus group participants. All tools were translated from English to the three local languages used in the study districts i.e. Lusoga, Lugwere and Ateso by three pairs of research assistants (RAs) who speak both English and the respective languages. All FGDs were tape recorded and the notes transcribed into English. Discussions on average lasted between 1 and 1.5 h. The qualitative data were analysed thematically. Analysis began with a detailed reading of the transcripts. Codes were then developed to identify and tag segments of text on the research topics of interest. After applying these codes to the transcripts, the researchers examined the coded text and generated broader themes that emerged from the data. The main themes in relation to key achievements were: awareness about maternal and newborn health, multi-sectorial collaboration, male involvement, improved care seeking, financial empowerment. The main themes in relation to challenges and lessons learnt were: poverty, facilitation, technical support and flexibility in the research approach. The quality checks that were implemented included the training of research assistants, pretesting of tools, field debriefing and review of data.

Based on the information provided, here are some innovations that were used to improve access to maternal health in rural Uganda:

1. Participatory Action Research (PAR): This approach involved working with households, saving groups, sub county and district leaders, transporters, and village health teams to diagnose causes of maternal and neonatal mortality and morbidity, develop action plans, take action, and learn from the results. This collaborative problem-solving approach helped to address the specific needs and challenges faced by the community.

2. Community Mobilization: Awareness about maternal and newborn health was raised through various communication strategies, including VHT home visits, community dialogues, talk shows, and radio spots. These activities aimed to improve knowledge and promote positive health practices in the community.

3. Strengthening Saving Groups: Saving groups were strengthened to provide financial support for transport costs, purchase items needed for birth, and meet other routine household needs. This helped to reduce the financial barriers to accessing maternal health services.

4. Linkages with Transport Providers: Improved linkages between saving groups and transport providers helped to enhance women’s access to health facilities at reduced costs. This innovation addressed the transportation challenges faced by pregnant women in rural areas.

5. Support for Village Health Teams (VHTs): VHTs, who are community health workers, played a key role in providing information and support. However, their efforts were constrained by low levels of education, inadequate financial compensation, and transportation challenges. Regular supervision, review meetings, and payment for supervisors to visit were implemented to ensure that VHTs and saving groups functioned effectively.

These innovations, implemented through the MANIFEST project, aimed to improve local awareness of maternal and newborn health practices and increase access to healthcare. The project emphasized collaborative problem-solving, continuous support, and a participatory approach to overcome challenges and improve outcomes.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the described project is to implement a participatory action research approach. This approach involves working with households, saving groups, sub county and district leaders, transporters, and village health teams to diagnose causes of maternal and neonatal mortality and morbidity, develop action plans, take action, and learn from the results in a cyclical manner.

The innovation should focus on building the capacity of community stakeholders and improving local awareness of maternal and newborn health practices. This can be achieved through community mobilization, which includes raising awareness through home visits, community dialogues, talk shows, and radio spots. These communication strategies should cover a wide range of topics, such as the importance of attending antenatal care, delivering in a facility, receiving postnatal care, encouraging male involvement in maternal health, birth preparedness, the benefits of saving money for healthcare expenses, and newborn danger signs.

Additionally, the innovation should strengthen saving groups and other saving modalities by providing support to improve income generation, management, and trust among members. Linkages between saving groups and transport providers should be improved to enhance women’s access to health facilities at reduced cost. Village health teams should be supported through regular supervision, review meetings, and adequate financial compensation to overcome challenges related to low levels of education and transportation.

Collaborative problem-solving among diverse stakeholders, continuous support, and a participatory approach that allows flexibility are essential characteristics of the innovation. Regular review meetings should be conducted to assess progress, identify challenges, and make necessary adjustments to improve outcomes and increase the chances of sustaining the initiatives.

By implementing this participatory action research approach, the innovation can effectively improve access to maternal health by harnessing community capabilities and resources to complement supply-side initiatives.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening communication strategies: Additional direct communication strategies should be developed to reach more men beyond the minority who attended community dialogues and home visits. This could include targeted messaging through various channels such as radio, social media, and community events.

2. Enhancing saving groups: Saving groups and other saving modalities should be further strengthened to improve income generation, management, and trust among members. This could involve providing training and support to the saving groups to enhance their financial capabilities and sustainability.

3. Improving linkages with transport providers: Linkages between saving groups and transport providers should be further improved to enhance women’s access to health facilities at reduced cost. This could involve establishing partnerships with transport providers and implementing mechanisms to subsidize transportation costs for pregnant women.

4. Enhancing the capacity of village health teams: Efforts should be made to address the challenges faced by village health teams, such as low levels of education, inadequate financial compensation, and transportation challenges. This could include providing regular supervision, review meetings, and payment for supervisors to visit.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Baseline data collection: Collect data on the current status of access to maternal health services in the target area, including indicators such as the percentage of women attending antenatal care, delivering in a health facility, and receiving postnatal care.

2. Define simulation parameters: Determine the specific parameters to be simulated, such as the increase in awareness about maternal and newborn health, the improvement in saving group capabilities, the increase in linkages with transport providers, and the enhanced capacity of village health teams.

3. Develop a simulation model: Create a simulation model that incorporates the defined parameters and their potential impact on access to maternal health services. This model could be based on existing data, research findings, and expert knowledge.

4. Run simulations: Use the simulation model to run various scenarios based on the recommended interventions. This could involve adjusting the parameters and assessing the potential impact on access to maternal health services.

5. Analyze results: Analyze the simulation results to determine the potential impact of the recommended interventions on improving access to maternal health. This could include quantifying the expected increase in the percentage of women attending antenatal care, delivering in a health facility, and receiving postnatal care.

6. Validate findings: Validate the simulation findings by comparing them with real-world data and feedback from stakeholders. This could involve conducting surveys or interviews to gather feedback on the effectiveness of the recommended interventions.

7. Refine and iterate: Based on the simulation findings and validation results, refine the recommendations and simulation model as necessary. Iterate the process to further optimize the interventions and their potential impact on improving access to maternal health.

By following this methodology, stakeholders can gain insights into the potential impact of the recommended innovations on improving access to maternal health and make informed decisions on their implementation.

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