Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework

BackgroundQuality Improvement (QI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect.Materials and methodsA qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARIHS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes.ResultsHealth workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention’s comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge.ConclusionComponents of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.研究背景：质量改进（Quality Improvement, QI）方法如今正愈发广泛地用于填补撒哈拉以南非洲地区母婴保健（Maternal and Newborn Care, MNC）领域的质量缺口。医护工作者通常同时扮演质量改进活动的接受者与实施者双重角色，其认知水平、工作动机与参与程度在很大程度上决定了相关举措的潜在效果。为支持坦桑尼亚各医疗机构并行推进的各类质量改进方法的统一化与整合工作，本研究旨在探究医护工作者对协作式质量改进干预措施的不同组成部分的认知与体验，进而明确其对干预效果作用机制的积极贡献。 材料与方法：本研究针对坦桑尼亚农村地区母婴保健领域的协作式质量改进干预措施开展质性过程评估。研究人员在13家经目的性抽样选取的医疗机构中，对16名医护工作者进行半结构化访谈。本研究采用基于演绎式理论驱动的质性内容分析方法，以整合版卫生服务研究实施促进行动（integrated Promoting Action on Research Implementation in Health Services, i-PARIHS）框架为分析视角，将其四大构面——创新、接受者、实施促进与情境作为核心指导主题。 研究结果：医护工作者高度认可质量改进主题与日常临床实践的高度契合性，并对该干预措施的系统化推进路径表示赞赏。用于监测工作进展的运行图（run-charts）的应用方式易于理解，且被医护工作者认为具备激励作用。多数医护工作者均提及，针对各医疗机构的现场指导与辅导式走访具有重要意义且体验积极。不少受访者表示，各类卫生项目的并行推进是一项现实挑战。 研究结论：医护工作者在日常实践中已充分理解且认为具备支持性的质量改进方法组成部分，或可强化干预效果机制并带来更为显著的变革。聚焦此类组成部分，还有助于指导统一化工作，避免项目重复与并行推进，并助力资源有限地区实现质量改进方法的本土自主实施。