Nompilo Study: Quality Improvement Intervention

Hloli Ngidi, MA20,000+ Partnership, University of KwaZulu-Natal, South Africa

Presenting on behalf of the Nompilo Study Team: C. Horwood, W. Ngidi, M. Grant, J. Reddy, P. Barker, L. Butler and N. Rollins

Need for effective methods to improve uptake of evidence-based interventions to reduce maternal and infant mortality

• SA has embraced community health workers (CHW) as a vital part of its health system;

• CHWs expected to provide a package of community-based maternal, newborn and child health and nutrition services, working as part of ward-based primary health care outreach teams;

• ~ 10,600 CHWs in KwaZulu-Natal, South Africa

Recognized Questions and Needs

How can we best utilize the pool of CWH to improve both MNCHN/PMTCT outcomes?

• All CHWs have received basic training in maternal & child health, but coverage and quality of training is variable;

• Need for updated training for the CHW on MNCHN/PMTCT;

• Need continued support – but limited evidence regarding best strategy for providing support and supervision to CHWs.

Rationale for Intervention

• No standardized supervision approach for CHW;

• No feedback mechanism for CHW;

• Quality Improvement (QI) methodology has been implemented to improve the delivery of healthcare services in South Africa – not previously tested with CHWs

Research Questions

Implementing integrated community case management training & QI support to CHWs:

• Is it feasible?

• Does it lead to gains in CHW knowledge, self-efficacy and practice?

• What is the effect on infant feeding practices, and uptake of PMTCT and MCH services?

Intervention

• Enhanced, data-driven supervisory approach• peer-to-peer learning networks of CHWs and their supervisors

• twice a month to review process and output data

• Flexible, local adaptation, highly participatory

• Evidenced-based tools aimed at rapid-cycle iterative testing of changes

QI Plan

1. Data driven improvement• Build a common goal• Agree on set of targets that are clear and practical• Identify data to feedback to CHWs to reflect their day to day activities

2. Effective supervision • Clearly identifying roles and responsibilities of supervisors• Supervisor meetings to empower/strengthen their supervisory skills• 'Study mentors' groom supervisors so they lead improvement work

3. Accelerate learning through collaboration• Team meetings (1 supervisor with 4 CHWs) • Groups share lessons learned similar focus on data• Encourage linkages in communities

Continuous Quality Improvement

• 3 day training for team leaders and 1 CHW per team

• Led by professional nurses with QI training

• High facilitator to participant ratio: 1:10

• Content:

• Leading and facilitating teams

• Use of QI tools – e.g., root cause and bottleneck analysis, mapping processes, PDSA

• Information / data usage

• Twice monthly mentorship team meetings by expert QI facilitators with CHW teams

• Collaborative learning sessions: 3 over 15 months

Twice monthly mentorship team meetings

Attendance by CHW Teams

Challenge Solution

Mothers in the communities hide their pregnancies not only from them but also from their families

Teenagers not willing to use protection before they have their first babies ( beliefs). Use of isihlambezo during pregnancy

More emphasis when giving health talks at schools as well as in households ( including grannies, and during school talks ) Talks during the ‘Imbizo’ meetings called by local traditional chifes, where impact of late attendance shared , and use of ‘isihlambezo’( trad meds) discouraged.

Some mothers do not want CHW to see their clinic cards. Some CHW felt that this is because mothers do not want to disclose their HIV status

Other CHW shared stratergies they used that were successful, e.g buidling trust with clients, communication skills, attending Operation Sukumasakhe meetings , meeting at ward level to share with other stakeholders and create buy in, as well as to be known in the communities where they work, visits cretches.

Challenges with referral clinics not giving CHW feedback on referred clients

District attended to the matter with project staff where all clinics were re-emphasised on the roles of CHW and the team work emphasized

Examples of challenges and solutions

Learning Session / Mentorship

• Facilitators and facilitation techniques were seen as central to the learning session process

• Participants felt they were afforded an opportunity to share and learn different and new ways of identifying pregnant women and mothers from other CHWs and they could also see how their work was going in general

• One highlight mentioned was that of having a member of DoH present which meant that CHWs were able to share any challenges directly with them

• Supported and mentored after the trainings

CHW felt empowered with knowledge

“Because you are now more knowledgeable and you carry a lot of tools that assist you with your work, the

timers, and thermometers; and you know which temperature requires a referral to the clinic...

… previously we did not have any tools when we visited people’s homes. You would just tell a person to keep their

house tidy and other such things. You could not do anything for them; if they told you that a person is sick

you would not be able to do anything for them. All we did was come to clean that person once they were bedridden

and could not do anything for themselves” (S08C03)

Conclusion

Simplified data driven approach can be implemented effectively with CHWs;• CHWs attended

• CHWs expressed their increased sense of self worth and professionalism

• CHWs liked it!

• Considerable effort was needed to establish the QI supervision approach;

• Without supervision, QI or other supervision approaches, investment in training may not yield the same results