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Study Protocol

A network of care to improve the continuity and quality of maternal and perinatal services in Makueni County, Kenya: study protocol

[version 1; peer review: 2 approved with reservations]
PUBLISHED 24 Apr 2024
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Abstract

Background

Kenya’s high maternal and perinatal mortality rates exceeds its recommended 2030 targets. The lack of effective collaboration between health facilities and workers contributes to delays and uncoordinated provision of care, leading to negative maternal and neonatal health (MNH) outcomes. Network of Care (NOC) is an effective strategy to improve health facility network efficiencies and MNH outcomes. Utilizing NOC to improve health system coordination and MNH outcomes in Kenya has not been studied. We present a study protocol for implementation research to investigate the feasibility and acceptability of establishing a county-level NOC on relationships among health facilities and workers, the feasibility of NOC for the Makueni county health system, and the impact of NOC on the quality of MNH services and emergency referrals within the county health system. Levels of communication, collaboration, and trust between NOC health facilities and levels of preparedness for management of MNH complications are also evaluated.

Methods

The study employed a mixed methods design with quantitative data from health worker self-administered phone surveys, health facility referral forms, and facility registers collected at baseline, then every three months from September 2021 to July 2023. Health worker focus group discussions and county management key informant interviews were conducted at baseline, midline, and endline. The study purposively selected 60 public and private health facilities in Makueni. These facilities were a sub-sample of 344 facilities with the highest maternity caseloads. A descriptive and thematic analysis of communication, collaboration, and trust between NOC health facilities and workers, and referral system changes will take place. Trend analysis of MNH indicators for Makueni from the Kenya Health Information System will be done.

Conclusion

This study aims at informing decision-makers locally and globally on whether NOC is feasible and acceptable as a county-level model of care in Kenya with application to similar LMIC settings.

Keywords

Network of Care, Maternal and Neonatal Health, Study Protocol, Implementation Research, Communication and Collaboration, Trust, Phone Survey, Kenya

Introduction

Maternal and perinatal mortality remains a major public health concern in Kenya. Kenya’s maternal mortality ratio (MMR) of 355 maternal deaths per 100,000 live births1, and the neonatal mortality rate of 21 deaths per 1000 live births1,2, far exceed the target of 113 maternal deaths per 100,000 live births and 12 neonatal deaths per 1000 live births respectively1,2. Current evidence suggests that poor quality of care in facilities that manage maternal and neonatal health (MNH) complications now contribute to preventable death in low- and middle- income countries (LMICs) more than poor access to care36, underscoring the importance of building capacity of health systems to deliver a higher standard of care. Additionally, the lack of effective collaboration between health facilities and health workers contributes to delays and uncoordinated provision of care, leading to negative MNH outcomes6,7. In Makueni county, as in many other Kenyan counties, poor communication and collaboration between health facilities coupled with inadequate infrastructure for delivering services results in delays during management and referral of MNH emergency cases, and poor MNH outcomes8,9. Makueni county’s MMR of 400 maternal deaths per 100, 000 live births10 exceeds the overall Kenya MMR1. This calls for a multi-faceted approach that addresses quality of care at childbirth, improves collaboration between public and private health facilities networks leading to a coordinated health workforce, reduces congestion at higher-level facilities so that true complications can be managed promptly, and strengthens referral systems to reduce delays in diagnosing a complication and seeking an appropriate level of care.

Network of Care (NOC) is a relatively new model that is gaining traction due to its potential to improve efficiencies in health facilities networks and ultimately MNH outcomes1113. The NOC model aims to improve 1) communication, collaboration, and trust among health facilities and 2) appropriateness and timeliness of referrals within the network, for better quality of MNH services and ultimately outcomes14. NOC also aims to build confidence and accountability among health workers by assisting them to understand their role in achieving a broader goal of quality services for positive health outcomes14. These elements can be considered the ‘software’ of the health system, guiding forces underpinning the relationships among health system actors and performance14,15. A case study from rural Madagascar demonstrated how an effective NOC can help achieve universal health coverage, reduce neonatal and under-five mortality and improve antenatal care attendance11. In Nigeria, implementation of the NOC model demonstrated increased access for women and families who might have been excluded from services and rapid referrals improving MNH outcomes12. Reducing patient volume at higher level facilities, a strengthened referral system, and dramatic improvements in MNH outcomes were observed with the implementation of the NOC model in Tanzania13.

The Clinton Health Access Initiative (CHAI) scoping study defines NOC as “a group of public and/or private sector service delivery sites deliberately interconnected through an administrative and clinical management model which promotes a structure and culture that prioritizes client-centered, effective, efficient operation and collaborative learning, enabling providers across all levels of care, not excluding the community, to work in teams and share responsibility for outcomes”14. The NOC model elucidates that an effective NOC demonstrates improved patient health outcomes in the targeted clinical areas, and accomplishes these outcomes by addressing four interconnected domains: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation14.

Despite evidence that a NOC improves MNH outcomes1113, the concept of NOC in LMICs is still nascent. This study investigated the feasibility and acceptability of establishing a county-level NOC on relationships among health facilities and health workers, the feasibility of NOC for the county health system, and the impact of NOC on the quality of MNH services and emergency referrals within the county health system.

Specific aims

Specifically, the study aimed to answer the following research questions:

  • 1. Does NOC improve communication, collaboration, and trust among study health facilities?

  • 2. Is NOC an acceptable intervention to be integrated into the current county and sub-county health care and referral systems?

  • 3. How feasible will it be (including the cost) to integrate NOC into existing county and sub-county care and referral systems?

  • 4. Does NOC improve health facilities’ readiness to manage maternal and neonatal complications and does it also improve maternal and neonatal referral processes?

A secondary objective, which is exploratory, was to describe selected MNH outcomes for clients in Makueni county during the study’s implementation. This objective was exploratory because a direct relationship between the NOC and the selected outcomes may not be determined.

This study will inform decision-makers locally and globally on whether NOC is feasible and acceptable as a county-level model of care in Kenya with application to similar LMIC settings. We used the SQUIRE 2.0 guidelines from the EQUATOR Network to report this quality improvement study protocol16.

Protocol

Context

The site for this study was Makueni county, one of the 47 counties in Kenya. Makueni county is situated in South-Eastern Kenya and has a population of approximately 900,000 people, with women of reproductive age representing 23% of the population10. Makueni county health management team (CHMT) provides the oversight and coordinating mechanism for MNH service delivery in the county. The NOC approach was introduced in 60 health facilities that provide MNH services and referrals (51 public, 9 private), across all the six sub-counties of Makueni county, namely Makueni, Kaiti, Mbooni, Kibwezi East, Kibwezi West, and Kilome sub-counties. Purposive sampling in consultation with the Makueni CHMT officials was used to identify the 60 health facilities. The selection was based on the geographical distribution (at least six facilities in each of the six sub-counties in Makueni) and maternity caseloads per month (these facilities reported the highest maternity caseloads in 2020 and represented 17% of the 344 health facilities in Makueni). The health facilities included levels II, III, IV, and V facilities. Level II health facilities are dispensaries, level III are health centres, level IV are sub-county hospitals, and level V is the main county referral hospital.

The NOC intervention description

The NOC intervention for maternal and perinatal health is defined as a collection of public and/or private health facilities and health workers in a defined geographic area that are deliberately interconnected to promote multi-disciplinary teamwork and collaborative learning. Health facilities within the network implement a package of interventions that follows a theory of change model (Figure 1) with the intent to improve MNH outcomes in both public and private health facilities. The intervention is co-implemented by health facility staff who are employed by the government or private sector and routinely provide MNH services, and county government officials from Makueni CHMT. The NOC package of interventions was designed and based on evidence and learnings from the CHAI scoping study14 (Figure 2) and includes:

8894ab95-e577-49be-87ed-b70b4a74f53c_figure1.gif

Figure 1. NOC Theory of Change.

8894ab95-e577-49be-87ed-b70b4a74f53c_figure2.gif

Figure 2. NOC domains and interventions as outlined in the CHAI scoping study14.

Domain I: Agreement and enabling environment

A sequential participatory approach was utilized to build support and buy-in from Makueni county stakeholders. First, several targeted planning meetings including an introductory meeting at the county level with approximately 35 participants, a meeting to identify communication mechanisms and determine data review meeting cadence with approximately five participants, and a meeting to review and finalize NOC materials with approximately five participants were conducted. Participants included several county stakeholders from Makueni CHMT to health facility staff at level II to V facilities. Following the planning meetings, health facilities were introduced to the NOC concept through an orientation meeting with approximately 90 participants drawn from the intervention facilities. During the health facility orientation meeting, mapping of the health facility resources across the county was done. Mapping included adapting, printing, and applying the mapping tool at all 60 intervention facilities within Makueni county. Mapping data were collected by a facility focal person/in-charge, shared with the sub-county reproductive health (RH) coordinator for validation and further shared with the sub-county health records and information officer and county RH coordinator for analysis and results generation. A county level NOC steering committee was then established comprised of Makueni CHMT, health facility focal persons and county records officers. The steering committee conducted a one day meeting with approximately 90 participants drawn from the intervention facilities to review the mapping exercise results, define a referral pathway and develop materials to streamline referrals. Roles and responsibilities of each intervention facility were also defined during this meeting. A half-day meeting that engaged approximately 90 participants drawn from the steering committee, Makueni CHMT, facility focal persons and records officers was then held to enable facilities to sign a collaborative agreement agreeing to participate in the NOC intervention. The finalized NOC materials were distributed during this meeting.

Domain II: Operational standards

The NOC materials including referral pathways were adapted, printed and distributed to each intervention facility during the signing of the collaborative agreement. These included maternal and newborn referral forms, referral registers and facility readiness assessment tool. The facility readiness assessment tools captured, on a monthly basis, information on supplies, guidelines, clinical skills, documentation, and ongoing referral mechanisms.

Domain III: Quality, efficiency, and responsibility

Mentorship support is an important element for building trust and relationships within the NOC, as well as driving improvements in quality of care. In Makueni county, the Makueni CHMT supports need-based mentorships that are informed by data, facility assessments, and mentee requests. Mentors – including clinicians and RH coordinators – were recruited at the county and sub-county levels based on their MNH experience and skills and visited NOC intervention facilities at least once every three months. During these mentorship sessions, facilities review their outcomes and analyze their reporting rates and existing quality indicators, and they address any quality of care issues.

To nurture and facilitate communication and coordination within the NOC, Makueni county selected and used the WhatsApp platform as one of its communication mechanisms. Facilities within the NOC used WhatsApp for consultation, problem solving, referral coordination, and information sharing. The WhatsApp platform was also used for clinical updates as well as identifying challenges and best practices. In addition, health facility focal points used phone call to inform about, manage, coordinate, and account for referrals between sending and receiving facilities.

Domain IV: Learning and adaptation

Data review meetings with approximately 78 participants drawn from the NOC intervention facilities, steering committee members, Makueni CHMT and MNH partners were conducted every three months to review service statistics and referral data across the county. Service statistics were assessed via facility readiness tools, registers and referral forms. The data review meetings also provided a forum for joint problem-solving around challenges faced by health facilities within the network. The research team also provided updates on study progress during the data review meetings.

Study team

International Centre for Reproductive Health Kenya was the local research partner responsible for measurement of study outcomes while Jhpiego supported Machakos county in the implementation of the NOC intervention and provided quality assurance.

Study design

This was a mixed-methods implementation research study. Both qualitative and quantitative data were collected. Health workers participating in the NOC intervention used their mobile phones to complete a self-administered survey at baseline and then every three months. A subset of those completing phone surveys participated in seven focus group discussions (FGDs) at baseline, midline, and endline. A subset of 24 Makueni CHMT members participated in key informant interviews (KIIs) at baseline, midline, and endline. Additionally, data was extracted from health facility readiness assessment tools, facility maternal and newborn referral forms, and facility referral registers. The study also monitored trends in MNH indicators for Makueni county from the KHIS.

Outcomes

The primary outcome, the impact of NOC on relationships among health facilities and health workers within the county health system, was assessed using a self-administered mobile phone-based questionnaire for health workers, data extracted from health facility referral registers and referral tools, and FGDs for health workers. Secondary outcomes of interest included the acceptability and feasibility of integrating NOC into the county and sub-county health care and referral systems including the cost. These outcomes were measured by program data, FGDs with health workers, and KIIs with Makueni CHMT. Exploratory outcomes included changes in selected MNH outcomes for clients in Makueni county and were measured from KHIS data.

Study participants

The target sample size for the study was 184 health workers. Purposive sampling was used to identify health workers to participate in the NOC intervention.

Study participants for the phone surveys and FGDs were selected in two stages. In the first stage, the research team engaged the facility in-charges of the 60 NOC health facilities to identify and list all staff working in MNH units and other relevant hospital departments. All health workers who provided MNH services were listed. In the second stage, health workers were selected based on profession (nurse/midwife, doctor, clinical officer, and emergency medical technicians), department (maternity, ANC, MCH, and outpatient), gender, and the number of years of experience in the health facility. The sample size for each level of health facility was determined by the number of health workers providing MNH services.

For the surveys, two health workers were sampled from each of the level II facilities, three from level III, four from level IV, and five from the level V facility with consideration for the increased number of health workforce with an increased level of health facility. For the seven FGDs, seven to ten health workers, a subset of those completing phone surveys, were purposively sampled per sub-county from each of the six sub-counties. An additional seven to 10 health workers were sampled across all the six sub-counties specifically from Newborn Units (NBU). The NBU-specific FGD was included to understand specific health worker experiences when handling unique neonate management challenges.

Makueni CHMT participating in the KIIs were purposively selected from the steering committee with additional non-steering committee members from all six sub-counties of Makueni county.

Data collection procedures

The research team conducted stakeholder meetings with Makueni CHMT and in-charges of NOC health facilities to share study objectives and seek permission to conduct the study. Four research assistants were trained to provide information on the study to eligible health workers and to Makueni CHMT, and to invite them to participate in the survey, FGDs, and KIIs.

Health workers who agreed to participate in the survey were required to provide written informed consent and a personal mobile phone number issued by the telecommunication provider Safaricom. Safaricom is the largest mobile telecom operator in Kenya with 63.6% market share and 94% 3G network coverage of the population17. Study participants received an orientation on how to respond to self-administered survey questions and submit survey responses through their mobile phones at the time written consent was obtained. The mobile phone number list of all consented participants was shared with the study Information Technology (IT) lead who then imported the mobile phone numbers on an unstructured supplementary service data (USSD) platform developed by Innovee Systems (T) Limited. The IT lead then activated the study time on the USSD platform to run for 21 days. Upon activation, the USSD system sent push notifications - short messages to study participants welcoming them to the USSD Platform and providing participant credentials to log into the survey together with a specific code to access the survey. The survey technology worked with all mobile phones. Participants who logged into the survey but did not complete their responses were sent automated reminders every 48 hours via a push notification from the USSD system until they completed the survey. Each question had a maximum of five possible responses, and each response led to the next.

Health workers who agreed to participate in the FGDs and Makueni CHMT who agreed to participate in the KIIs were also required to provide written informed consent. FGDs and KIIs were conducted in person by a trained researcher at a venue that offered privacy with the aid of interview guides and tape recorders. The interview language was English since all participants had a tertiary level of education. Data collection involved probing to gather information until saturation was achieved. Interview audio recordings were saved on tape recorders.

Phone survey questionnaire

The study used a questionnaire format that was validated during a previous study on measuring health workers’ communication, collaboration, and trust (Nuño-Solinís et al.)18. The questionnaire was adapted and tailored to the Makueni county context with input from Makueni CHMT and NOC steering committee members. The questionnaire was comprised of 17 questions, which covered four main domains: (i) Perceived health worker confidence to manage MNH emergencies and referrals based on existing resources, (ii) Perceived health worker accountability for the management of MNH complications and ensuring the best outcomes, (iii) Perceived levels of collaboration, communication and trust among health workers and health facilities when managing MNH emergencies and referrals and (iv) Perceived appropriateness and timeliness of referrals. The responses were graded on a five-point Likert Scale from 1 to 5, whereby 1 corresponded to “disagree strongly”, 2 for “disagree somewhat” 3 for “neutral”, 4 for “agree somewhat” and 5 for “agree strongly”. Piloting of the survey questionnaire was done in October 2021 to refine the tool. The questionnaire is available at Open Science Framework19.

FGD and KII interview guides

The FGDs and KIIs used a semi-structured interview guide on topics including:

1.   Communication, collaboration, and trust between health facilities;

2.   Confidence in the ability to manage complications and the level of accountability in health facilities;

3.   Acceptability and feasibility of integrating NOC into existing county and sub-county health care and referral systems;

4.   Appropriateness of the referrals to other facilities and trust in their capacity to handle cases;

5.   Sustainability of the NOC.

The FGD and KII interview guides are available at Open Science Framework19.

Data management and statistical analysis

Once the health workers submitted the phone surveys, these were sent to a cloud-based server via the telecommunications provider Safaricom. The data was aggregated there before being downloaded to a secure server for data cleaning and validation checks by the study analyst. Before analysis, data was checked for errors, inconsistencies, completeness, and accuracy. Frequency distributions were computed by age category, gender, duration worked in the facility, cadre, department, and level of health facility. The internal consistency of the items in the questionnaire domains was assessed using Cronbach alpha. Chi-square tests will be computed to assess for associations.

All interview audio recordings were downloaded to a password-protected computer and stored in a project folder. Audios were transcribed and translated where necessary and stored as Microsoft Word documents. Transcribed data was iteratively read through, and themes identified. Data will be analyzed with NVivo 12 (Open access alternative: LiGRE). Charting will be done to link the specific quotes with the themes, and thereafter interpretation will be done. Signed written informed consent for all study participants was filed and kept in lockable cabinets at ICRHK offices.

Ethical considerations

The study was conducted with ethical approval from the Amref Ethics and Scientific Review Committee (Protocol number 1016/2021 – 10/08/2021), and the National Commission for Science, Technology and Innovation (NACOSTI – 26/08/2021) in Kenya. A non-human subjects research determination was approved by the Institutional Review Board at the Johns Hopkins University in the USA (IRB00017146 – 02/08/2021). All study participants were required to provide written informed consent.

Dissemination

The study team plans to disseminate findings among global, national and sub-national stakeholders through in-country dissemination events and globally through peer-reviewed journal manuscripts and international conference presentations.

Study status

At this stage, baseline (September 2021 – October 2021), midline (October 2022) and endline (July 2023 – August 2023) data collection is complete. Analysis of the survey questionnaire, health facility abstracted data, and FGD and KII audios is still ongoing.

Discussion

Kenya still faces a range of health system challenges, but the progress that has been made in maternal and neonatal health suggests that coordinated efforts and additional investment will lead to new solutions20. However, finding those solutions and improving MNH quality of care will only be evident through decreasing the fragmentation of care for pregnant women, improving referrals, and improving access to primary care services2123. Strong inter-facility collaborations and relational linkages between public and private health facilities and providers, implemented within a local county government system, offer a promising solution to improve the continuum of MNH care and MNH outcomes2123. A high-functioning NOC with more efficient and effective systems for providing quality, people-centered, coordinated care within the public and private sector can address inefficiencies within the Makueni county health system that are impacting quality of services and limiting progress towards achieving MNH goals. This study has potential to demonstrate how local county government led initiatives can facilitate positive changes.

The study model has the potential to demonstrate the short-term impacts of NOC. Little is known about the effects of NOC on health workers' perception of their confidence, accountability, communication, collaboration, and trust when managing MNH complications and how this can improve the quality of MNH services. Additionally, this is one of the first studies to measure these attributes using mobile phone technology and lessons learned from the use of phone surveys in the measurement of these attributes can inform similar studies in other contexts.

The study also has the potential to demonstrate that NOC can be cost-effective without significant financial inputs. This study uses non-financial incentives to engage health workers and a separate costing analysis will be conducted at the end of the intervention drawing from program data on resources needed to implement NOC. If this NOC proves successful, as an affordable initiative led by county governments, there is an opportunity for the expansion of this network to various counties in Kenya and its adaptation to diverse situations in low and middle-level income countries (LMICs). The availability of this evidence comes at an opportune moment, as LMICs are actively involved in the process of broadening NOC to enhance MNH outcomes on a broader scale. Countries striving to diminish MNH mortality can draw valuable insights from the experiences gained through this NOC.

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Owira P, Mulwa D, Kiptoo O et al. A network of care to improve the continuity and quality of maternal and perinatal services in Makueni County, Kenya: study protocol [version 1; peer review: 2 approved with reservations]. Gates Open Res 2024, 8:34 (https://doi.org/10.12688/gatesopenres.14851.1)
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Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 24 Apr 2024
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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