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Pediatric HIV/AIDS
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Tanzania | Iringa Region Infant Feeding Improvement Collaborative
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Collaborative Profile
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Comparison of Coaching Strategies for Improvement Collaboratives in Ugandan HIV/AIDS Health Centres
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Publications
HCI has been implementing centrally organized collaborative improvement, with coaching provided by technical experts outside the MOH hierarchy, in 113 sites in Uganda to improve health care for patients with HIV/AIDS since 2006. In 2008, HCI introduced a district-based coaching strategy using MOH district management structures, as an alternative to centrally organized coaching, to facilitate sustainability of the approach and encourage its institutionalization and greater country ownership in the Ugandan health system.This study’s goal was to measure the relative efficiency and effectiveness of the two strategies in achieving improvements in process indicators.The study found that there were mostly very small improvements in quality indicators for both district and central strategy sites but these were generally not associated quality improvement team performance (QITP). There were some differences in QITP in four of 13 team indicators but no difference in improvements between district and central strategy sites. The district strategy was about 1/5th the cost of the Central strategy cost and therefore significantly more efficient. We therefore recommend the MOH use the district rather than the central strategy for more widespread interventions.HCI is preparing a manuscript for journal submission.
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Améliorer la documentation et le maintien des patients dans le programme de prise en charge du VIH en Côte d’Ivoire
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Publications
En 2008, à la demande du Ministère de la santé, avec l’appui financier du PEPFAR, le Projet d’Amélioration des Soins de Santé de l’USAID (HCI) a été invité à assister le Programme National de Prise en Charge des personnes vivant avec le VIH (PNPEC) pour conduire une évaluation nationale de la qualité des soins dans le domaine du VIH en Côte d’Ivoire. HCI et les partenaires de mise en œuvre ont conduit une évaluation nationale de la qualité des soins et services offerts aux PVVIH. Sur la base de l’évaluation, un comité technique dirigé par le PNPEC avec l’appui technique d’URC a développé un paquet de changement pour améliorer la documentation, le suivi et la rétention des patients. Ce rapport décrit les résultats du collaboratif d’amélioration d’ARV/PTME.
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Nicaragua | Antiretroviral Therapy (ART) Improvement Collaborative
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Collaborative Profile
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BASICS Pediatric HIV Tool-kit: Orphan and Vulnerable Children Situational Analysis Interview Guide for Community Groups
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Community Resource
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IMPROVING QUALITY OF CARE IN RURAL HIV CLINICS THROUGH CLINICAL DATA AUDITS: EXPERIENCE FROM NORTHERN NIGERIA.
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Improvement Report
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Spread of PMTCT and ART Better Care Practices through collaborative learning in Tanzania
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Publications
This evaluation takes place in the context of the “Partnership for Quality Improvement” (PQI) initiative in Tanzania. The partnership was initiated in 2007 by the Tanzania National AIDS Control Program (NACP) and PEPFAR to improve the quality of ART/PMTCT services in Tanzania through the implementation of a harmonized approach to modern quality improvement. At the time of this report, the Health Care Improvement Project (HCI) and PharmAccess International (PAI) are providing technical leadership to facilitate shared learning among ART/PMTCT collaboratives managed by implementing partners (FHI, CHAI. EGPAF, AIDS Relief etc.) and regional health management teams in Tanga, Morogoro, Mtwara and Lindi.
Within the partnership, learning developed within one partner’s collaborative should lead to rapid uptake of effective changes by other teams, leading to desired level of results for all teams. Sharing this learning should not be limited just within that region or that implementing partner, but spread to other regions supported by other partners as well. This ability to build on learning within regions, within partners, across regions and across partners is important for efficient achievement of better care and better outcomes for people affected by HIV and AIDS.Research questions/objectives:This evaluation seeks to study the mechanisms and results of the spread of better care practices in the Partnership for Quality Improvement. Identifying facilitating and hindering factors for shared learning and spread will help determine how learning among peers and spread of better care practices can be strengthened within the PQI context. The specific objectives of this evaluation are:1. To describe the various steps involved in the change process including the origin of ideas, their testing and implementation and their subsequent spread to other teams.2. To determine the various internal and external factors influencing the change process and identify means to augment the effects of favorable factors and remove barriers.3. To explore the role of the higher levels of the health system and collaboratives in catalyzing the spread of best practices and their scale up.The lessons learnt from this evaluation will provide guidance to quality improvement programs in other countries for strengthening learning among peers and improving spread within a collaborative approach or in other quality improvement efforts.Methodology:This is a cross-sectional evaluation which involves both quantitative and qualitative methods of data collection. All sites in the 3 regions (Tanga, Morogoro and Mtwara) whose collaboratives have been operative for more than 6 months were included in this evaluation (total of 29 facilities). Data was collected by interviewing the quality improvement focal person of facility teams and through focus group discussions with QI team members.Results:Results of the evaluation showed that the improvement collaborative is indeed facilitating sharing of ideas. Across the three regions, the great majority of ideas are “borrowed “from other teams, managers and coaches; with Tanga and Morogoro borrowing almost 70% of ideas, while in Mtwara 40% of the ideas had been borrowed. This indicates that ideas gained from participating in the collaborative are the main sources of adopted changes. The HCI/Tanzania project team composed a list of 16 effective changes (as of January 2010. Of these 16 effective change ideas teams had tried an average 12.6 changes per facility. Four of these 16 changes were tried by all facilities: issuing a 2 month supply for clients living far away; reorganizing patient charts for easy retrieval, establishing a mother-child register to link children to their HIV+ mother; and issuing Co-trimoxazole in the Reproductive Health Clinics.Learning sessions and coaching were the primary mechanisms for being exposed to or sharing changes with other teams, but other meetings, site visits, and phone calls were also used. Teams desired detailed information about “how to carry out” the changes they are being exposed to. Not all changes were found to be equally spreadable – spread of ‘better care practices” depended upon how straight-forward their implementation is and whether teams possessed the authority or resources to implement the activity. Staff engagement and staff resistance were cited as important factors impacting the implementation of a change. Implementation also depended upon external technical support, facility leadership and capacity for change. At present, the sharing across collaboratives has been mainly dependent on the role of the HCI/PAI team to create the linkages across collaboratives and regions. Additional mechanisms for sharing learning across a network of regions are needed, as well as mechanisms for sharing learning within a region that build on existing structures and opportunities. -
Investigation of the Sequential Validity of QI Team Self-Assessments in a Health Facility HIV Improvement Collaborative in Tanzania
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Publications
This is a study of the validity of the QI Teams’ self-assessment of their own performance as part of the ART/PMTCT improvement collaborative in Mtwara region, considering all the steps in the self-assessment process. Data collection began in August 2009 with baseline data collection by new QI teams as part of their QI work. Four rounds of data collection evaluated improvements in: completeness of case recording, record storage and retrieval, sample selection for abstraction, abstraction, summary, and communication of findings. The study found that validity of self-assessment data generally improved over the life of the collaborative.
This study has been submitted for publication in a peer-reviewed journal, and will be availble when published.
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Effects of participating in collaborative improvement on the quality of HIV/AIDS care in facilities in Cote d’Ivoire: a comparison of intervention and control sites
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Publications
Collaborative improvement is one approach being used in many countries to improve prevention of mother to child transmission (PMTCT) and treatment with anti-retroviral therapy (ART) services. Collaborative improvement is consists of a network of teams engaging in a structured effort to learn from one another. A recent study analyzing the experiences of 27 collaboratives in 12 countries has shown collaborative improvement’s potential in achieving significant improvements in the level of the quality of care and the sustainability of such results. However, this is one of the first studies in developing countries that examines the effect of collaborative improvement in comparison to a control group.The Ministry of Health of Cote d’Ivoire and the USAID Health Care Improvement Project (HCI) launched a collaborative improvement initiative in December 2008, in collaboration with implementing partners. The collaborative operated in two phases: the initial demonstration phase, which began in January 2009, and the extension (spread) phase, initiated in August 2010. This collaborative provided an opportunity to: 1) examine whether there is a significant difference in the level of the quality of care between sites that have participated in an improvement collaborative versus those sites that will be in the extension phase and have therefore not yet participated in the collaborative activities; and 2) identify the factors contributing to this difference (if any) in the quality of care provided in the intervention and control sites.MethodologyThis study uses a modified quasi experimental design, in which the intervention group includes those sites participating in the demonstration phase of the ART/PMTCT collaborative, and the control group is composed of spread sites which had not yet been exposed to the collaborative activities but were planned to be included in the spread phase. Data were collected from 36 of the original 41demonstration (intervention) sites, and 42 spread (control) sites.ResultsIntervention sites saw significantly more improvement in quality of care indicators than control sites for completeness of documentation for PMTCT and ART, and for testing of children born to HIV+ mothers. Complete documentation for PMTCT at intervention sites rose from 22% at baseline to 83% after the collaborative, whereas at control sites during the same period there was only an 8% increase (from 0% to 8%); Complete documentation for ART at intervention sites rose from 22% at baseline to 87% after the collaborative, control sites had a higher baseline at 46% but this indicator barely showed any improvement at the end of the year (49%). Testing of children born to HIV+ mothers also increased at intervention sites. Results related to loss to follow-up for intervention sites do show initial improvement but some of the gains were lost towards the end of the study period. However, control sites experienced significant increases in loss to follow-up over time. Data availability was significantly lower in control sites than in intervention sites.QI competency and implementation were significantly higher in the intervention group, as were having a standardized process that would allow maintaining gains, mechanisms for orienting new staff, and systems for ensuring resource availability. Few differences in resource availability were noted. Control sites had a higher percentage of clinically trained providers. Intervention sites were likely to have generated change ideas themselves or borrowed these ideas from other participating sites rather than control sites, which, if they implemented the change, were mostly likely to have received the idea from their implementing partner.Regression analyses, holding other independent variables fixed (resources and clinical competence), showed a strong association between being involved in the collaborative and results related to documentation and testing of children born to HIV+ mothers.Conclusions and RecommendationsThis study has shown that facilities involved in collaborative improvement are able to achieve significant improvement over their own baseline results in comparison to sites that have not participated in a collaborative. Regression analysis indicates a strong association between being involved in the collaborative and improved documentation and increased testing of children born to HIV+ mothers. Time series charts also indicate potential impact on loss to follow-up, although the results were not as well maintained over time. This study is one of the first of its kind in a developing country to demonstrate the effects of participating in collaborative improvement on results achieved in comparison to a control group.
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Uganda – Retention Collaborative
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Collaborative Profile
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Uganda – HIV/ART Coverage Collaborative
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Collaborative Profile
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Uganda ART Collaborative
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Collaborative Profile
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Counseling Cards
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Publications
Counseling Cards
The counseling cards are intended for health workers to use during sessions with HIV-positive prenatal and postpartum women. Published in English and Swahili, the cards are tools that health workers can use to explain: the risk of transmission of HIV from mother to child when no preventive actions are taken; infant feeding options for HIV-positive mothers; the concept of acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding; and how to safely practice their chosen infant feeding method.Risk of Passing HIV from Mother to Baby
Using this counseling card as a guide, the health worker can show the client a graphic depiction of the risk of passing HIV from HIV-positive women to their babies when NO preventive actions are taken. The card shows that most babies are infected with HIV during pregnancy and birth (approximately 20%). It also depicts the rate of babies who become infected with HIV through breastfeeding (approximately 15%) The health worker can use the card to illustrate that the majority of babies (approximately 65%) are not infected with HIV, but should be protected through the use of ARVs and safer infant feeding.Infant Feeding Options
This counseling card is intended to assist healthcare providers counsel women who have tested HIV-positive. It offers graphic depictions of three of the most common methods being actively promoted for feeding infants of HIV-positive women in Tanzania so that the healthcare worker can guide the mother in determining the safest option for feeding her baby.Infant Formula or Modified Cow's Milk as a Safe Option
This counseling card is directed to women who have tested HIV-positive and who are exploring their infant feeding options.This graphic job aid enables counselors to discuss whether using infant formula or modified cow’s milk presents a safe and secure alternative to breastfeeding, following AFASS criteria.Risk of HIV passing from mother to baby if mother and baby take Nevirapine
Using this counseling card as a guide, the health worker can show the client that the risk of mother passing HIV to baby decreases the mother practices exclusive breastfeeding and mother and baby take Nevirapine.How to Breastfeed
This job aid is intended to assist the counselor to give clear instructions to pregnant women on how to breastfeed. Illustrated, step-by-step instructions are presented to promote good positioning of the baby to prevent breast problems which can increase the transition of HIV through breastfeeding.How to Hand Express Breast Milk
This counseling card graphically depicts the steps for the mother to follow to hand express breast milk, an important skill for all mothers to have, no matter what their status. It encourages the use of a cup rather than a bottle for feeding the baby.Many Ways to Position and Attach Baby
Using this counseling card as a guide, the healthcare worker can show the mother a range of ways to position and attach the baby.During the first 6 months, baby needs only breast milk
This card illustrates that during the first six months, the baby should be given only breast milk.The mother should avoid giving water, glucose water, and all other foods and drinks.Danger Signs
Danger signs indicating that the baby should be immediately taken to the nearest health facility are illustrated. -
Job Aids on HIV and Infant Feeding
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Publications
Health workers in many countries struggle with how to advise women on acceptable, feasible, affordable, sustainable, and safe (AFASS) options for infant feeding in the context of HIV. Making an informed decision about infant feeding is particularly critical for HIV-positive women to reduce the risk of HIV-transmission to their infants.
WHO, UNICEF, UNAIDS, and UNFPA recently updated their joint guidelines on infant feeding options for HIV-positive women, but such international reference materials often are not available in a form useable by frontline health workers. Tanzania is one of the first countries to develop—and now apply on a national scale—a comprehensive set of job aids on infant feeding and HIV/AIDS that feature high impact graphics and easy-to-follow instructions, reflecting the international guidelines aimed at reducing the risk of transmission of HIV from mother to child.
The need for counseling job aids reflecting the updated international guidelines was first identified during the development of the a global compilation of programme evidence by URC/QAP in 2003 and formative research conducted in Tanzania. The materials were adapted from several generic counseling tools designed by WHO, UNICEF, and USAID. Funded by USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR), development took place under QAP-supported operations research conducted in 2004 in close collaboration with the Univerity of Bergen, Norway and the Kilimanjaro Christian Medical Centre (KCMC) in Moshi District, Kilimanjaro. The Ministry of Health and the Tanzania Food and Nutrition Centre (TFNC) were major contributors, as were a number of other organizations and national stakeholders An interactive and systematic process was followed to allow both international experts and national stakeholders to review, critique, provide inputs and guide decisions at strategic points throughout the development phase. Stakeholder consensus was an important consideration in the final design of the job aids.
Healthcare workers throughout Tanzania are currently being trained to effectively use the tools to counsel prenatal and postpartum women to make informed decisions about their infant feeding options and to help women safely practice their chosen infant feeding method. The materials use compelling graphics and easy-to-follow text to facilitate their use and understanding of key messages. To create the imagery, QAP’s team used a state-of-the-art process that employs digital photography, imagery scanning, and computer design graphics.
The Ministry of Health of Tanzania is providing substantial direction in the training of nurse counselors and the disseminating of the job aids in multiple regions of the country through government facilities. Reflecting growing interest in the adapatation of these job aids for other settings, QAP has worked with national authorities in Uganda and Zimbabwe to adapt the job aids for use by both their National Programmes for the Prevention of Mother to Child Transmission (PMTCT) and Infant and Young Child Feeding (IYCF).
Published in English and Swahili, the integrated set of materials include:
- • Question and Answer Guide: HIV & Infant Feeding – Answers to questions commonly asked by mothers, their families and communities
- • Counseling/Take Home Brochures: Exclusive Breastfeeding, Infant Formula, Cow’s Milk, Expression and Heat Treatment, Nutrition, and Feeding a Baby
- • Counseling Cards: Relative Risk of Transmission (100 babies), Infant Feeding Options, AFASS, Positioning and Attachment, and Expression and Heat Treatment of Breast Milk
Although the materials were developed for use with women in antenatal care clinics and postpartum clinics, the tools are also being used with women in other settings, as well as with fathers, elders, youth, local leaders and others in the community.
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Take-Home Brochures
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Publications
Six take-home brochures provide illustrated and easy-to-follow guidelines to enable prenatal and postpartum women to make informed decisions about which infant feeding option is the most acceptable, feasible, affordable, sustainable, and safe (AFASS) for each individual's situation and to help women safely practice the option selected. The brochures graphically depict the step-by-step procedures for women to use in carrying out each of the four infant feeding options.
How to Breastfeed Your Baby
This take-home brochure provides mothers with an illustrated guide and detailed step-by-step instructions on how to start and continue breast feeding. It provides information on how to recognize and prevent problems, lists signs to look out for, and identifies what mothers need to remember and know.How to Hand Express Breast Milk
This illustrated brochure graphically depicts and provides mothers with instructions on how to hand express. It includes points to remember and tells mothers how to safely store and feed the milk to the baby. This method is being promoted for use by HIV-positive mothers during the transition from exclusive breastfeeding to replacement feeding in order to minimize the dangerous period of mixed feeding.How to Heat Treat Breast Milk
An insert to the above brochure shows how to safely heat breast milk.How to Feed Your Baby Fresh Cow's Milk
HIV-positive mothers who opt to feed fresh cow's milk to their babies are given a complete list of steps and ingredients needed for safely modifying and feeding fresh cow’s milk to babies. The brochure outlines how to make fresh cow’s milk more nutritionally appropriate for infants. It visually presents the preparation process, stresses the importance of hygiene, and encourages the use of cup feeding. Additional points to remember are covered.How to Feed Your Baby Infant Formula
HIV-positive mothers who opt to use commercial infant formula to feed their babies are given a complete list of steps needed to safely prepare formula and feed their babies. The brochure visually presents the preparation process, stresses the importance of hygiene and encourages the use of cup feeding. Additional points to remember are covered.Nutrition: During Pregnancy and Breastfeeding
Pregnant and breastfeeding women are reminded of the importance of taking a test to determine HIV-status. By becoming aware of their status, HIV-positive women are then able to consult their healthcare providers to determine an appropriate course of action for antiretroviral therapy and nutrition. The brochure points out that good nutrition is especially important to HIV-positive mothers and their infants and gives illustrated pointers on safely preparing foods and planning balanced meals. General points covering meal frequency, water consumption, and diet supplementation are given, and women are reminded to follow their healthcare providers' instructions.Feeding a Baby: After Six Months
This brochure addresses questions that mothers may have regarding how to feed babies who, after six months, are beginning to eat semi-solid foods. HIV-positive women, the brochure notes, should consult a healthcare provider to determine whether it would be best to give another type of milk in place of breast milk. It points out that after 6 months, babies need to gradually begin eating a variety of foods and gives information on types of foods, as well as correct consistency and amounts, to give to babies aged 6, 7-8, 9-12, and 12-24 months. The brochure gives instructions for safe food preparation and storage and covers a range of other points. -
HIV & Infant Feeding Question and Answer Guide
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Publications
The HIV & Infant Feeding Question and Answer Guide is intended as a reference tool to provide health workers with information concerning updated international guidelines related to HIV and infant feeding. Health workers can refer to the Guide to explain the complicated and difficult issues related to HIV and infant feeding, provide information and support to help prevent HIV transmission from women to their children, and increase the safety of all infant feeding options, including exclusive breastfeeding, commercial formulas, modified cows' milk, and expressed and heat-treated breast milk. It gives easy-to-understand answers to some of the most common questions that mothers, their families, and communities ask about HIV and infant feeding. The Q&A Guide is based on a generic UNICEF PMTCT infant feeding counseling tool and on the content of the WHO/UNICEF HIV and Infant Feeding Counseling Tools.
