We found solutions as leaders The Added-Value of Leadership, Management, and Governance Training for Postpartum Family Planning Service Providers Research Findings Wednesday, April 6, 12:00-1:30 pm EDT USAID Training Room 9082, 2100 Crystal Drive, Arlington, VA
Presentation Overview: Background and Context Program Overview Study Methodology Study Results Implications for practice & research
BACKGROUND Family Planning Context in Cameroon Photo: 2012 Akintunde Akinleye/NURHI, Courtesy of Photoshare
Family Planning Context Total fertility rate was 5.1 (2011) increase from 5.0 in 2004 Wide regional and urban/rural variation in modern contraceptive use among married women Current use of modern contraception methods among unmarried youth 15-19 is 50.8% Unmet FP need among married women is 23.5% Source: DHS, 2011
Barriers to PPFP Service Delivery & Uptake Supply side Low HR capacity in maternity to offer FP counseling & services High workloads in maternity Bottlenecks & non-integrated FP services Limited space to provide one-on-one counseling Instability of FP commodities availability Demand side Cultural norms that favor large family size, status with many children Women lack RH/FP decision-making agency Misconceptions about contraceptive side-effects Lack of FP/PPFP educational campaigns/materials Baba Djara M. et al (2015) Baseline Study Report: The Added-Value of a Leadership Development Program on Postpartum Family Planning Service Delivery. Leadership, Management, and Governance Project
SRH/FP policy context Key stakeholders consider SRH/FP a priority MOH requesting TA to increase FP service delivery for postpartum (PP) women Prioritizing LARC, PPIUD, & YFFP services FP commodities security improving National RH/MNCH Plan is finalized
PROGRAM OVERVIEW & STUDY DESIGN Photo: 2015 Arturo Sanabria, Courtesy of Photoshare
Intervention Partnership L+M+G Capacity Building LDP+ PPFP Service Delivery Strengthening Ongoing FP commodities security program
Levels of Health System Capacity Building LDP+ E2A Adapted from MEASURE Evaluation, 2003
Study Aim To evaluate the added-value of a Leadership, Management, and Governance capacity building intervention on PPFP service delivery within MNCH departments of tertiary hospitals
Study Design Prospective Quasi-experimental mixed methods design Purposively sampled, non-equivalent intervention and comparison sites Arm #1 2 hospitals FP commodities Clinical capacity building Arm #2 2 hospitals FP commodities Clinical capacity building Arm #3 2 hospitals FP commodities LDP+ strengthening
Arm #1 2 hospitals Arm #2 2 hospitals Arm #3 2 hospitals FP commodities FP commodities FP commodities E2A Clinical capacity building Clinical capacity building LDP+ strengthening
E2A - Clinical Capacity Building Program PPFP Counseling and Clinical Training Facility improvements Supervision activities Quality assurance Data collection/mis
Arm #1 2 hospitals Arm #2 2 hospitals Arm #3 2 hospitals FP commodities FP commodities FP commodities Clinical capacity building Clinical capacity building LMG LDP+ strengthening
Leadership Development Program Plus
Program Theory of Change Factors Influencing PPFP Service Delivery Improvements Communication/feedback Education PROCESS Leadership Task Integration CONTENT Information Accessibility Applicability Awareness CONTEXT External: Competition External Mandates Reimbursement Internal: Culture/climate Resources/support Structure/staffing Workload Adapted from the Consolidated Framework for the Advancement of Implementation Research (CFIR), Damschroder et al, 2009 further adapted by Alexander & Hearld, 2011
Hospital Characteristics by Study Arm LDP+ Non-LDP+ Hospital Characteristics Arm 1 Arm 2 Arm 3 Hospital 2 Hospital 3 Hospital 4 Hospital 1 Hospital 5 Hospital 6 Classification District Reference District Reference District Reference Governance MOH Autonomous MOH MOH MOH Autonomous # Maternity beds 6 47 11 70 12 52 # Ob/Gyns 1 15 4 10 2 7 # MNCH nurses 15 24 18 40 14 44
Study Questions and Measures How does L+M +G strengthening influence the process and outcomes of a PPFP service delivery intervention as compared to FP clinical capacity building and commodities provision alone? Question Qualitative Quantitative Content, contextual, and process barriers and facilitators to PPFP service delivery within MNCH services? LDP+ training s influence on FP service delivery attitudes and practices of PPFP service providers? L+M+G capacity building influence on workrelated stress in the context of PPFP integrated service delivery as compared to clinical capacity building provision alone? FGD (Pre, midterm, & post) Interviews (Pre & post) FGD (Pre, midterm, & post) Interviews (Pre & post) L&M Behavioral Self-Assessment (Pre & post) WRS Instrument (Pre & post)
Study Questions and Measures What influence does L+M+G capacity building have on PPFP service delivery outcomes as compared to clinical capacity building and FP commodities provision alone? Outcome Measures Qualitative Quantitative PPFP service delivery outcomes % of ANC clients receiving FP/SRH counseling % of clients delivering at the hospital who receive FP/SRH counseling Couple Years of Protection (CYP) by method type PPFP health system outcomes # and proportion of SDPs providing PPFP counselling or services # and types of contraceptive options available for PP women Proportion of SDPs that have PPFP IEC materials for clients Proportion of SDPs that have PPFP job-aids for providers Record Review (Pre & post) Observation & Record Review (Pre & post)
Study Participants Baseline Sample (individuals) Endline Sample (individuals) Qualitative Key Informant Interviews 7 8 Semi-Structured Interviews 10 8 Focus Groups 6 (1 FGD) 11 (2 FGDs) Quantitative Behavioral Self-Assessment 11 11 WRS Survey 136 116 Outcomes Data Collection 6 (hospitals) 6 (hospitals)
Limitations of the Study Design Study sites were not randomly selected Small sample size (2 hospitals/arm) Small number of LDP+ participants Hospital capacity not the same at baseline Limitations taken into account in data analysis methodology
WHAT WERE THE OUTCOMES? LDP+ influence on FP service delivery Photo: 2012 John Kihoro/Tupange(Jhpiego Kenya), Courtesy of Photoshare
*α =.05, p=.02
*α =.05, p=.02
*α =.10, p=.0722
HOW DID LDP+ INFLUENCE SERVICE DELIVERY OUTCOMES? LDP+ influence on FP service delivery Photo: 2012 Jhpiego, Courtesy of Photoshare
Added Value of L&M Capacity Building External Context Intervention Characteristics & Processes Internal Context Characteristics of Individuals
Added Value of L&M Capacity Building on Internal Context Individual Characteristics Culture/Climate Attitudes towards FP Resources/Support Self-efficacy HR structure/staffing Knowledge Workload Leadership engagement
Added Value of L&M Capacity Building on Intervention Process Communication & feedback Education Task Integration Engaging Documentation Reflecting & Evaluating
When it comes to human resources, in the beginning we had an issue since the delivery room-- each team has two members, but sometimes we have 3 women in labor and also some cases where we have 2 women giving birth at the same time. So it is not realistic to assist with the birth, to give counseling, to adopt a method but after, we found solutions. Since we trained a considerable amount of caregivers, when it is crowded at maternity, we can call someone from ANC or we can call one from the postdelivery room, we could also ask help from the coordinator in charge. (204_T3) Human Resources & Training
Individual Attitudes towards FP/PPFP Q: And how would you say that it (LDP+) influenced PPFP services offered? R: Naturally, when you don t know, when you don t believe in what you do, it goes without saying that if you don t have the right information, if you yourself are not convinced, you will not be able to convince whomever is in front of you to adopt a method. So as long as the staff is fully briefed on the service, who should benefit, how it should be done etc., I think the limitations due to personal beliefs is no longer an issue. So, we think that with the trainings we have improved adherence of our clients and our providers to treatment protocols. (305_T3)
Well, a concrete example We were trained with E2A in service delivery among other things. Now after the training, we were separated... We needed leadership so that thanks to leadership we were able to learn other strategies. It was thanks to leadership we learned that it was important to limit the wait times for the woman to return that we needed, before she left, to introduce the fees for the next consultation into the delivery fees so that when the woman would arrive we would take her directly into the room. So it is thanks to the leadership [training] that we were able to find this solution. (FGD_T3)
Implications for practice & research Building MNCH health personnel s L+M+G capacity contributes to PPFP service delivery improvement by: Improving health personnel s attitudes towards FP/PPFP Improving organizational learning culture & problem solving skills Improving collaboration & teamwork Improving service delivery task integration
Conclusion Our findings suggest that integrating L+M+G capacity building into clinical service delivery interventions can lead to improved service delivery results over and above the effect of clinical training by collectively addressing organizational culture and structural barriers that impede service delivery innovations.
Any Questions? Thank you! THANK YOU
Resources Cameroon DHS, 2011, http://dhsprogram.com/publications/publication-fr260-dhs-finalreports.cfm Baba Djara M. et al (2015) Baseline Study Report: The Added-Value of a Leadership Development Program on Postpartum Family Planning Service Delivery Baba Djara M. et al (2015) Implementation Report: The Added-Value of a Leadership Development Program on Postpartum Family Planning Service Delivery Alexander, J. a, & Hearld, L. R. (2011). The science of quality improvement implementation: developing capacity to make a difference. Medical Care, 49 Suppl(12), S6 20 Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. a, & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science : IS, 4, 50.
For more information contact: Monita Baba Djara, DrPh, MS Principal Advisor, Monitoring and Evaluation Leadership, Management, and Governance Project Management Sciences for Health mbabadjara@msh.org
Further Information ADDITIONAL SLIDES
Study Timeline Study Set-up Sept-Nov LDP+ Intervention Feb- July Endline Data Collection Aug-Oct 2014 2015 LDP+ Results Meeting Baseline Data July Collection & Report Dec-Feb 2016 Data Analysis & Final Report Nov- April
Quantitative Data Analysis Data L&M Behavioral Self-Assessment Pre- and post- assessments WRS Survey Pre- and post- assessments Service-Delivery & Health System Outcomes 3 month pre- and 3 month post- data collection Analysis Cronbach s α, factor analysis Paired t-test One sample t-test Cronbach s α, factor analysis Paired t-test Difference in Differences test Pearson s correlation One-way ANOVA, MANOVA, MANCOVA Difference in Differences test
Qualitative Data Analysis Data Key Informant & Semi-Structured Interviews Pre- and Post Interviews Focus Group Discussions Pre-, Midterm, and Post FGD s with LDP+ Participants Analysis Deductive Coding Independent & Reconciled coding Nvivo 8