Village Health Workers

The FGDs were held in a convenient location, mainly in the church or home of a participant or village health worker. They were facilitated by SAfRI research assistants who are Ugandan scientists, nurses and psychologists who hold degrees and have previous experience in qualitative research. Their roles included taking notes, audio recording the session, and ensuring the discussion ran smoothly. One research assistant from each session acted as the moderator who asked questions from the pre-formulated topic guide and facilitated the running of the FGD.
A topic guide (Fig. 3) was developed, consisting of open questions formulated to explore participants’ answers in detail. As this was an iterative process, the topic guide was adapted after each focus group during team debrief sessions. This topic guide was used to direct the discussion of participants’ interpretation of the poster, suggestions of other moments for hand hygiene, and whether participants reported compliance with the moments for hand hygiene.Fig. 3

Topic guide for focus group discussions

A total of 55 pregnant women of over 34 weeks’ gestation were recruited to the intervention arm of the BabyGel study, from 5 villages. These villages were situated around Busiu Health Centre IV in Mbale District, Eastern Uganda and were selected to represent a variety of distances from each other, market areas and from the health centres. Participants were taught to use the hand rub at certain moments in their daily routine, as defined by the ‘Newborn Moments for Hand Hygiene’ poster. This was made available to all those in the intervention arm as a laminated colour poster in English or the dominant local language Lumasaba. The participants were taught verbally to use the ABHR at the moments specified in the poster and were supported by Village Health Workers.
At the end of the 3-month neonatal period, mothers from the intervention arm were invited to attend a focus group discussion (FGD) to offer their opinion on the acceptability and feasibility of the educational poster and ABHR. All 55 women in the BabyGel study intervention group were invited to participate, regardless of their level of education or literacy. A total of 35 women agreed to participate. Five focus groups were conducted throughout March and April 2016, each consisting of 6–8 participants, as summarised in Table 1.Table 1

Demographics of FGD Participants

Village	Number of participants	Mean age of participant (range)
Namakye	8	22.6 (18–30)
Bulwalasi Toma	8	27.9 (19–37)
Namunyu	6	27.5 (19–39)
Makhonje 1	7	23.1 (19–30)
Makhonje 2	6	30.3 (19–36)

Most participants were married and described their occupation as a housewife or peasant farmer. Most had only primary education. The typical house was made from mud with an iron sheet roof. Most had non-ventilated pit latrines without handwashing facilities.
The FGDs were arranged by telephone call during the participants’ 90-day follow-up survey. On the day of the focus group, a research assistant from the Sanyu Africa Research Institute (SAfRI) formalised the participants’ consent prior to the discussion.

The design and methods of SHINE have been reported previously,² (link) and the protocol and statistical analysis plan are available online. Briefly, SHINE was a cluster-randomised, community-based 2 × 2 factorial trial in two contiguous rural districts in Zimbabwe (Chirumanzu and Shurugwi). The districts have a 15% prevalence of antenatal HIV⁸ and a high prevalence of schistosomiasis, but a very low prevalence of soil-transmitted helminths.⁹ (link) Rotavirus vaccination was introduced during the trial from May, 2014. Households are usually single-family dwellings surrounded by farm land. Before the trial, mean distance between households was 82·6 m,¹⁰ (link) and population density was 18·6 people per km². Clusters were defined as the catchment area of between one and four village health workers (VHWs) employed by the Zimbabwe Ministry of Health and Child Care. Urban and uninhabited areas were excluded. Between Nov 22, 2012 and March 27, 2015, VHWs prospectively surveyed new pregnancies, established the date of last menstrual period, and referred pregnant women to SHINE research nurses, who enrolled eligible women. Women were eligible for inclusion if they permanently resided in a study cluster and were confirmed pregnant. During the recruitment period, the cutoff of gestational age for eligibility was gradually loosened (from 14 weeks' gestational age to just before parturition) to maximise recruitment (appendix). The Medical Research Council of Zimbabwe and the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health approved the study protocol. All participants provided written informed consent.

The basic feature of the PeriKIP social innovation was that trained facilitators supported local stakeholder groups at the commune level and at district and provincial hospital levels in their efforts to improve perinatal healthcare practices. Seven laywomen from the Women’s Union were recruited as facilitators on the commune level. Facilitator positions were advertised openly, and recruitment was based on applicants’ previous experience with community activities and communication skills. A retired director (physician) of the Reproductive Health Centre on the provincial level in Cao Bang was recruited and trained to take the role as facilitator in the participating four hospitals. The project was implemented within the existing healthcare system [37 (link)] to increase the local accountability and ownership of quality improvement among stakeholders responsible for health (see Table 1). The PeriKIP groups at the three different levels were expected to meet once a month for the project’s duration. Participating in meetings and actions within PeriKIP was expected to be part of the stakeholders’ duties. Therefore, none was paid for their engagement besides the village health worker and the Women’s Union worker from the village level, who were reimbursed for travel expenses enabling them to attend monthly meetings.Table 1

PeriKIP group stakeholders at three health system levels

Stakeholder groups at the commune level: Each commune has one Commune Health Centre providing primary healthcare. In each of the communes in the study area (n=48), one PeriKIP group was established with the following eight participants: three Commune Health Centre staff (head of Community Health Centre, midwife and nurse), one village health worker, one vice chairperson of the Peoples committee, one women union representative from community level, one women union representative from village level and one population officer

District and provincial hospital level: In each of the district hospitals in the study area (n=3) and in the provincial hospital (n=1), one PeriKIP group was established with the following eight participants: one midwife from the antenatal care clinic, one midwife from the labour ward, the head nurse of the paediatric department, the head of the obstetric department (physician), the head of the paediatric department (physician), the head of the general planning department, the leader of the hospital director board and one representative from Reproductive Health Centre at district or provincial level

During 2 weeks, the research group trained locally recruited facilitators with theoretical sessions, group discussions and role-play activities. Topics covered group dynamics and quality improvement methods (brainstorming and the PDSA cycle). To facilitate discussions about perinatal care, the facilitators were introduced to basic evidence-based neonatal care per recommendations in the Vietnamese National Guidelines in Reproductive Health Care [38 ]. Also, facilitators were briefed on the current health situation in their respective districts and the function of the healthcare system concerning reproductive health. Guides on facilitators’ roles, attitudes, responsibilities and how to handle challenging situations were based on the i-PARIHS framework [24 ] and modified materials from the NeoKIP project [39 (link)]. At the end of the training, facilitators practised their skills in rural communes and district hospitals outside the study area followed by feedback discussions on performance. One person with reproductive health responsibilities from each district was recruited as a mentor of the facilitators working in the communes of that district. These persons attended the facilitator training and participated in separate sessions focusing on how to mentor facilitators. A guide describing the role of the mentors was also developed and used to support the mentors in their roles. Members of the research group were not involved in delivering the intervention to the local stakeholder groups. Trained facilitators within PeriKIP received a monthly salary.

Facilitators participated in focus group discussions (FGDs) after the training, 6 months later and after completing the project. A total of 15 FDGs with homogeneous groups of PeriKIP stakeholders from the commune level were undertaken in each district after 12 months: village health workers (n = 3), vice-chairpersons (n = 3), midwives (n = 3), commune health centre heads (n = 3) and Women’s Union representatives (n = 3). The rationale for undertaking FGDs with homogeneous groups was to understand how different stakeholders perceived their roles in the groups, allowing for potentially critical comments about other stakeholders’ involvement. One FGD was undertaken with each of the PeriKIP groups at the hospital level (n = 4) and one with the three mentors. Lastly, one individual interview was undertaken with the Reproductive Health Centre director in Cao Bang province after 12 months of implementation. The qualitative data collection aimed at understanding the mechanisms of change: the acceptability, usefulness, and operationalisation of the intervention at different levels [42 (link), 43 ]. The question guides were inspired by the i-PARIHS [44 (link)] and the UK Medical Research Council framework [41 (link)]. The FGDs and the interview were audio-recorded and lasted 60–90 min.

Two pairs in the research team (one neonatologist and one paediatrician in the first pair, one paediatrician and one general physician in the other pair) analysed the relevance of the identified problems and actions taken based on facilitators’ diaries from the 52 facilities. The independent scoring of each analyst was discussed to reach a consensus. A maximum score of 22 points could be obtained in the knowledge assessment (1 point for each correctly answered question). Baseline and endline results were compared across levels of the health systems (commune health centres and hospitals) and categories of health workers (physician, midwife and nurse). Data from the antenatal care observations were compared before and after the 12 months of PeriKIP intervention. Data from knowledge assessment and observations were entered using EpiData (version 3.1) and analysed in SAS (version 9.4). Descriptive statistics included proportions, means with 95% confidence intervals and t-tests with p-values.
The qualitative data were transcribed verbatim, translated into English and analysed by content analysis with both inductive and deductive features [45 (link)]. First, each interview of each type (midwives, village health workers, PeriKIP groups at hospitals, facilitators) was read several times to get a naïve understanding. This step informed the decision to approach the material as one data set. After that, open coding was undertaken. Codes were written in the margin of each interview describing aspects of the content. Codes were sorted into sub-categories; thereafter, sub-categories were sorted under categories, and finally, categories were placed under four main categories, i.e. the i-PARIHS dimensions (Innovation, Recipients, Facilitation and Context). One relevant category, Gaining knowledge and insights, as identified in the qualitative analysis, could not be sorted under the i-PARIHS dimensions. This category is presented together with the study outcomes.