Evaluating a community participatory quality improvement process: what works and what can be improved?
Capell, Jennifer Rosemary
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Problem: Maternal mortality in Ethiopia remains high, with 676 women dying per 100,000 live births. Infant mortality (68 deaths per 1,000 live births) is also high. The Ethiopian Government has committed significant resources to improving these outcomes, including training and deploying health extension workers (HEWs) to every community. The "What it Takes to Reach the Last 10 Kilometers" (L10K) project assists the government in increasing the reach of HEWs and improving the quality of the services. One L10K intervention is Participatory Community Quality Improvement (PCQI), in which the community and health workers are involved in defining and improving health service quality. This dissertation addresses three PCQI-related research questions: 1) What aspects of PCQI are working, and what implementation changes are recommended, 2) does PCQI improve service quality at rural health posts, and 3) does PCQI improve utilization of key maternal and neonatal health services? Methods: Mixed methods were used to answer the research questions. Key informant interviews were conducted with PCQI stakeholders, including health workers and administrators, and community members. Health facility assessments (HFAs) were conducted in 16 health facilities where PCQI was implemented prior to the start of PCQI, and again after one year of implementation. Service utilization data on key maternal and neonatal health indicators were collected from the same facilities for the 12 months preand post-implementation of PCQI. Interview data were analyzed for emerging themes, while service utilization and HFA data were analyzed using appropriate statistical tests and run charts. Results: Interviewees reported that PCQI increased awareness of and access to health services (66% of interviews); empowered communities to take ownership of health and health care issues (60%); promoted more respectful care of patients (40%); and improved HEWs' skills and confidence (19%). Challenges and recommendations included increasing technical support for HEWs (64%); further integrating PCQI into existing government systems (49%); and mitigating resource shortages (47%) and the turn-over of PCQI facilitators (38%). The number of women delivering with a HEW increased post intervention (p=.048). Conclusions: Involving communities and health workers in quality improvement can help increase respectful care and community empowerment, as well as increasing deliveries with health workers.
Thesis (Dr.P.H)--Boston University