Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation

IntroductionWe implemented a participatory quality improvement strategy in eight primary health care units of Ethiopia to improve use and quality of maternal and newborn health services.MethodsWe evaluated the effects of this strategy using mixed-methods research. We used before-and-after (March 2016 and November 2017) cross-sectional surveys of women who had children 0–11 months to compare changes in maternal and newborn health care indicators in the 39 communities that received the intervention and the 148 communities that did not. We used propensity scores to match the intervention with the comparison communities at baseline and difference-in-difference analyses to estimate intervention effects. The qualitative method included 51 in-depth interviews of community volunteers, health extension workers, health center directors and staff, and project specialists.ResultsThe difference-in-difference analyses indicated that 7.9 percentage points (95% confidence interval [CI]: 1.8–13.9%) increase in receiving skilled delivery care between baseline and follow-up surveys in the intervention area that is attributable to the strategy. The intervention effect on postnatal care in 48 hours of the mother was 15.3% (95% CI: 7.4–23.2). However, there was no evidence that the strategy affected the seven other maternal and newborn health care indicators considered. Interview participants said that the participatory design and implementation strategy helped them to realize gaps, identify real problems, and design appropriate solutions, and created a sense of ownership and shared responsibility for implementing interventions.ConclusionsCommunity participation in planning and monitoring maternal and newborn health service delivery improves use of some high-impact maternal and newborn health services. The study supports the notion that participatory community strategies should be considered to foster community-responsive health systems.引言 本研究在埃塞俄比亚的8家基层医疗卫生机构（primary health care units）推行了参与式质量改进策略，以提升孕产妇和新生儿健康服务的可及性与服务质量。 方法 本研究采用混合方法研究（mixed-methods research）对该策略的实施效果进行评估。我们针对家中有0~11月龄子女的女性开展了基线（2016年3月）与随访（2017年11月）两次横断面调查（cross-sectional surveys），对比39个接受干预的社区与148个未接受干预的社区的孕产妇和新生儿健康服务指标变化。我们采用倾向得分（propensity scores）在基线阶段对干预社区与对照社区进行匹配，并通过双重差分分析（difference-in-difference analyses）估算干预效应。质性研究部分包含51场深入访谈，访谈对象涵盖社区志愿者、健康推广员、卫生中心管理人员与工作人员以及项目专员。 结果 双重差分分析结果显示，干预组地区在基线与随访调查之间，接受专业助产服务（skilled delivery care）的比例提升了7.9个百分点（95%置信区间[CI]：1.8%~13.9%），该效应可归因于本策略。该策略对产妇产后48小时内接受产后护理（postnatal care）的干预效应为15.3%（95%置信区间[CI]：7.4%~23.2%）。但本研究未发现该策略对其余7项纳入分析的孕产妇和新生儿健康服务指标存在显著影响。受访对象表示，参与式的设计与实施策略帮助他们发现服务短板、识别真实问题并设计出适配的解决方案，同时强化了社区对干预措施落实的主人翁意识与共同责任。 结论 社区参与孕产妇和新生儿健康服务的规划与监测工作，可提升部分高影响力的孕产妇和新生儿健康服务的利用率。本研究支持如下观点：应考虑采用参与式社区策略，以构建响应社区需求的医疗卫生体系。