Barriers, facilitators and priorities for implementation of WHO Maternal and perinatal health guidelines in four lower-income countries: A great network research activity

Background Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO’s Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael’s Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these. Methods We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers). Results Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver highquality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators. Conclusion This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed. A mixed-methods (qualitative and quantitative) study was conducted in each of the four participating countries (Myanmar, Uganda, Tanzania and Ethiopia), adapted from the methodology developed in the Kosovo pilot study.[18] For each country, Phase 1 comprised a three-step process: establishing a multi-stakeholder group in each country to identify local maternal health guideline priorities (Step 1); conducting mixed methods research in the participating country to identify priorities, barriers, and facilitators to guideline implementation (Step 2); and developing an implementation plan, that incorporates contextualized implementation strategies, in accordance with findings from Step 2 (Step 3). Steps 2 and 3 were conducted during a 2-day in-person workshop with relevant local stakeholders. All steps were conducted with local partners (who were co-principal investigators). Subsequent implementation activities are currently ongoing, with support from the GREAT Network. We developed a generic protocol describing the methods and outputs for this activity, allowing for local adaptation where required. The study protocol was approved for technical content by the WHO Research Project Review Panel; the WHO Ethics Review Committee reviewed the project and deemed it exempt from review. Relevant local approvals were obtained (where required) in each country (see below). Participating countries were identified through purposive sampling. Within each country, activities related to a specific guideline implementation challenge, identified as a national priority at the time of the activities. In Myanmar, the activity was conducted in the context of a Ministry of Health initiative to improve the coverage of basic maternal and newborn healthcare nationwide, with particular emphasis on task-shifting from midwives to auxiliary midwives (AMWs). Uganda, Tanzania and Ethiopia were identified as priority countries within the UN Commission on Life Saving Commodities for Women and Children, which aims to improve access to 13 essential commodities (including the maternal health commodities oxytocin, misoprostol and magnesium sulfate). In-country activities were conducted in Myanmar in June 2014, Uganda in August 2014, Tanzania in November 2014 and Ethiopia in May 2015. Using an integrated KT approach, the first step was to identify key stakeholders. In each country, local investigators were identified via existing networks. Composition of the local working groups generally included 3–5 individuals from maternal health research organizations, clinical obstetrics, Ministry of Health, civil society and the WHO country office. A series of virtual meetings were held with this group to review KT principles, discuss local implementation priorities and to plan activities. A consensus approach was used to select the guideline/s of interest, based on their knowledge of relevant local initiatives and priorities and with informal consultation with other local stakeholders (such as Ministry of Health, United Nations (UN) agency or university staff). In each country, an anonymous survey was conducted to obtain understanding of key priorities related to the WHO guidelines, used to inform discussions and deliberations at the in-person workshops (see below). Surveys differed slightly between countries (S1–S4 Files) for individual surveys used in each country), however all included questions on: the respondent’s demographic and professional information, their current role and responsibilities, and perceived maternal health guideline priorities or factors affecting their uptake. In Myanmar, participants were asked to rate their agreement on the extent to which a list of factors were barriers to the use of the WHO task-shifting guidelines in their setting. In Uganda, Tanzania and Ethiopia, participants were asked to prioritize recommendations for implementation from the selected WHO guidelines. The local working group created a list of relevant local stakeholders (minimum 50), based on existing networks and websites of relevant organizations. This stakeholder list included healthcare providers (such as obstetricians, paediatricians, midwives and nurses), policymakers, healthcare administrators, program managers, researchers, non-governmental organization (NGO) staff, UN agency staff, professional association representatives, and other stakeholders from relevant local organizations. Participants were invited to complete a survey (the survey stated that consent was implied upon completion of the survey) and reminders were sent at approximately two and four weeks.[20]. Both paper and online surveys were used to maximize responses and ensure that those with limited or no web access were not unduly disadvantaged from participating (both surveys used same questions). The two-day in-person workshops aimed to incorporate perspectives from a diverse range of healthcare system stakeholders. The objectives of the workshop were to utilize these multiple perspectives to identify barriers and facilitators to guideline implementation, select priority recommendations, and identify potential implementation strategies to improve guideline uptake. Primary data collection occurred during the workshops, including focus group discussions (FGDs), an anonymized individual ranking exercise (using an electronic audience response system), and small and large group discussions. Workshop participants were purposively sampled (using the stakeholder list described above), with the aim of recruiting 20–35 participants per country. To ensure representation from across the healthcare system, healthcare administrators, policymakers, non-governmental organization staff, representatives from professional associations, frontline healthcare providers, and healthcare system researchers/academics were identified and recruited. Individuals from different levels of the healthcare system (eg: regional, district and facility level) were identified. A particular emphasis was placed on recruiting relevant opinion leaders and decision makers, as well as ensuring participants from rural and urban areas. Prior to the workshop, participants received information on the objectives of the workshop, as well as a summary of the guideline(s) (translated where necessary). The workshop was co-chaired by local working group members and international partners. Translators were available as required. Day 1 included a presentation of key principles of knowledge translation and the WHO guideline development process, as well as national maternal and newborn health indicators and priorities. Findings of the pre-workshop survey were presented, to provide additional information from other stakeholders for workshop participants to consider when deliberating priority recommendations for implementation. Subsequently, two to four in-person FGDs (of 6 to 8 people each) were held, lasting up to 2 hours each. Each FGD was co-facilitated by a nominated workshop participant and a researcher from WHO or St Michael’s Hospital. A customized FGD guide was developed by the research team and was adapted for each country workshop (S1–S4 Files). FGDs were organized by cadre to facilitate disclosure by participants. The objectives of the FGDs were to identify and explore priorities, barriers and facilitators to the adaptation and implementation of relevant guideline recommendations. Informed consent was obtained prior to the commencement of FGDs. The FGDs were digitally recorded and field notes taken for analysis. On Day 2, findings from Day 1 activities were fed back to participants, including a preliminary analysis of priorities, barriers and facilitators. Participants were asked to complete an anonymous individual ranking exercise (via the electronic audience response system) to identify the extent of consensus and to prompt reflection for further deliberation. With this system, each participant is able to vote anonymously in real time with results presented immediately. The ranking exercise was based on the modified Delphi technique, which is used to gather input from participants who may have differing views and perspectives. Participants ranked priority recommendations in terms of relevance and feasibility for implementation in the local context. Consistent with the RAND appropriateness method,[21] ratings were based on a nine-point Likert scale. When responses for a given recommendation were highly disparate, large group discussion took place and responses were re-ranked with the aim of reaching a higher level of agreement. On Day 2, participants reconvened in small groups to identify potential strategies for implementing the prioritized recommendations in their practice settings. Participants were encouraged to link proposed implementation strategies back to the underlying barriers that would be addressed, and leverage identified facilitators. Small group discussions were co-facilitated by an experienced researcher and a workshop participant nominated by the group. Deliberations were digitally recorded and field notes were taken for analysis. Descriptive statistics were calculated on quantitative survey data. For the qualitative data, all FGDs and small group discussions were audio taped and transcribed. Qualitative analysis of the transcripts and field notes was performed independently by two qualitative analysts using a thematic content analysis approach.[22] First, the analysts familiarized themselves with the data to develop initial coding themes. Second, these themes were further refined into categories that were ultimately used to develop a coding framework. Third, all transcripts were then coded by the analysts independently using the revised framework. Inter-rater reliability was compared once all transcripts were coded using percentage agreement; any discrepancies (i.e., < 80% agreement) between the analysts were reconciled through discussion.[23] Analysis was conducted using NVivo 10 software. A technical report for each country activity (containing a summary of quantitative survey data, and the qualitative analysis) was disseminated to workshop participants and other relevant stakeholders (S1–S4 Files).