The findings are presented as Implementation (reach and dose), Mechanisms of impact and Context (quality of facilitation, of the social innovation and the context in which it was implemented) and Outcomes (relevance of the identified problems and completion of the PDSA cycle, understanding of perinatal health issues, antenatal care practice, and accountability of quality improvement processes).
Launching meetings were organised to introduce PeriKIP and create buy-in at provincial and district levels. On provincial level, there were representation from the Provincial Health Bureau and the Provincial-level Reproductive Health Centre as well as district-level leadership representation from the Population committee, the Women’s Union and the hospital leadership from each of the included districts. At the launching of the PeriKIP on district level, there were representatives from the commune level, i.e., representation from the Population committees (Nguyên Bình 16/20; Hà Quảng 17/19; Phục Hòa 9/9), Women’s union (Nguyên Bình 18/20; Hà Quảng 14/19; Phục Hòa 8/9) and the Commune health centres (Nguyên Bình 20/20; Hà Quảng 19/19; Phục Hòa 9/9), the district level including representation form the District hospitals, the District Health Bureau and the District-level Reproductive Health Centres as well as representation from the Provincial-level Reproductive Health Centres.
Attendance to PeriKIP meetings
In total, 12 meetings were held in each commune (total 576 meetings across all included communes) and 18 meetings at each hospital (total 72 meetings across all included hospitals). Overall, the mean attendance of different representatives at PeriKIP group meetings was 95% (range 86%-100%) (Table 1).
[Table 1 here]
Mechanisms of impact and context
In total, the 48 communes identified and initiated actions to tackle 416 problems during 12 months, while the four included hospitals identified and initiated actions targeting 88 problems during 18 months. Below, we present the qualitative findings using i-PARIHS’ dimensions as main categories (Table 2).
[Table 2 here]
The initiation of PeriKIP meetings was positively influenced by careful anchoring of the social innovation at the Provincial Health Bureau and the Reproductive Health Centre at the provincial and district level. All communes and hospitals were informed about PeriKIP from within the system. At the beginning of the implementation phase, i.e., the first 2-3 months, the facilitators were tense and many stakeholders found the meetings’ intention unclear. Some feared the social innovation to be a way for higher levels to exercise control. The facilitator and the mentor spent time developing a trustful relationship. The groups initially focused on relatively limited and achievable problems. By the end of the project, all stakeholders could explain the purpose of the innovation and clearly describe the different steps of the PDSA cycle. The cycle provided an opportunity for everyone to contribute to the discussion, a structured way to review current practices, and a method allowing participants to register improvements and their impact.
Overall, the social innovation was perceived as useful, and the Plan and Study steps provided a structure of the work. Previously, many activities had been initiated but neither perceived to be adapted to the local context nor appropriately evaluated. Groups were encouraged by improvements that happened because of the groups’ actions. Although many stakeholders had attended a range of meetings at the commune health centre or hospital in the past, they perceived PeriKIP meetings to be different. The main reason was that the facilitator encouraged participation by all stakeholders, whereas previous meetings focused on passive reporting. Initially, the groups moved slowly and stakeholders were quiet, but later the teamwork improved and all stakeholders could share ideas and became friendly and confident to participate in the discussion.
Overall, the stakeholders perceived their inclusion as key to achieving the objective of PeriKIP. Some thought the activities could be improved with more stakeholders in the group, e.g., having representatives from all villages in the commune-level groups. Others suggested additional stakeholders, e.g., representatives from the youth union that could contact newly married couples, or from farmers union that could bring up issues of food security and nutrition but also be a communication channel to their members to ensure that perinatal health and survival to be on the agenda also in other sectors of society.
Stakeholders could clearly articulate the reason for their involvement and provide a rationale for the participation of others. It was clear that they acknowledged the different stakeholders of the group as experts in different areas. Local authorities’ engagement was commonly mentioned as a prerequisite for success, including the authorisation given by the district health bureau.
PeriKIP stakeholders identified problems based on their understanding of the local situation and by using available statistics. Issues were prioritised based on the feasibility of finding a solution (time, skills, knowledge, funding, and other resources), the urgency or severity of the outcome, and commonality. If stakeholders disagreed, they voted. Some villages in the same commune had different problems, why groups opted to address those in parts of their commune. The stakeholders listed resources used for action, e.g., materials used when sensitising community members. They would also ask facilitators to help finding new knowledge or act as a bridge to the Reproductive Health Centre’s resources.
The opinions varied whether the social innovation should be integrated into routine practice. The participants articulated a fundamental understanding of the PDSA process, including all its steps, recognised the benefits of engaging different stakeholders, and recognised an external facilitator’s role as catalysts. The perception was that the facilitator had other skills than the PeriKIP group stakeholders, and the fact that a person came to the commune solely for this purpose gave weight to the meetings. However, several suggested that this activity could be integrated into other arrangements, e.g., the commune health centre’s meetings with all village health workers. As such, the social innovation and the PDSA model were seen as a way of working that could be sustained, maybe in a slightly different format.
The PeriKIP group environment was inclusive with an active engagement in discussions. This characterisation was brought forward as a critical trait of the groups. The monthly meetings were fora for dialogue, mutual learning and formulating common goals.
Both facilitators and stakeholders recognised that the social innovation depended on all contributing to the group’s work and ensuring accountability of the activities. All stakeholders considered themselves and found other stakeholders to be essential for the group. The vice-chairperson stood out as a decision-maker in the commune groups, and in the hospital, the hospital, the head had that role. The participation of these individuals was indispensable for the facilitators.
The understanding of perinatal health problems varied within the groups and over time. Some stakeholders recognised gaining new knowledge; others got upset when stakeholders were ignorant. Stakeholders identified high attendance, being on time, and sharing responsibilities as principles for a well-functioning group. Initially, time for regular monthly meetings was a challenge in the hospital groups and some stakeholders were frustrated when identified problems were judged not to be feasible to tackle.
Both the facilitator and mentor positions were advertised for, thereafter recruitment followed.The facilitators recruited in the PeriKIP project shared several factors motivating them to become facilitators, including a wish to contribute to improving the health of women and children, changing and developing the situation in their area, and increasing awareness and knowledge of perinatal health among community members. In addition, facilitators also mentioned motivational factors relating to their situation, such as increasing their understanding of quality improvement and having a monthly salary.
The two-week training of facilitators was considered sufficient. During the training, facilitators gained a relatively clear understanding of their role. Undertaking role-plays and field visits were challenging but essential parts of the training. Some of the facilitators wanted more practical training, including communication skills. The mentors received the same training as facilitators and, in addition, separate sessions about their specific tasks. The facilitator and mentor guides were perceived as useful, and the content was generally sufficient to fulfil their functions.
At the start of the project, the facilitators were tense, but they were more confident in their roles after a few meetings. They developed their role by updating themselves on the internet and interacting with other facilitators and mentors. The distance was a barrier to interaction with others, and they wished for more regular opportunities to share experiences.
The study participants appreciated the facilitators. Facilitators had a dynamic role, varying with context and stakeholders. Study participants mentioned that facilitators asked stakeholders about perinatal health experiences from their villages, using non-technical terms, respectfully acknowledged participants’ contributions. They kept contact with community members, summarised meetings, took notes, kept track of members’ duties, encouraged and enthusiastically guided the discussions.
The facilitators trained group participants in the PDSA method and provided support throughout the project. Study participants expressed that the facilitators supported the stakeholders in the quality improvement processes. This assistance involved problem solving and encouragement but without making decisions for the group. The facilitator was seen as a person who understood the situation and supported the learning process. For example, the facilitators used the experience from one commune when helping another. The national guidelines for reproductive health (38) were introduced to the PeriKIP groups and used as sources of information when preparing for monthly meetings and selecting problems and actions.
Non-attendance required facilitators to act swiftly, contacting the missing stakeholder, stressing the importance of their contributions, updating the content they had missed, and sometimes involving the vice-chairperson or hospital head to motivate them to attend. When counteracting non-attendance, the assignment of the PeriKIP initiative was emphasised by higher health system levels.
The facilitators played an essential role in the PeriKIP project. They needed to be active and dynamic. At the commune level, the facilitators functioned well despite their lack of clinical experiences, but it was regarded as a necessity to have a professional health background at the hospital level. It was suggested that retired health care staff could be used as facilitators.
The mentors attended meetings to support the facilitators and kept in contact via mobile phones. The mentor provided support with clinical knowledge, through interaction with PeriKIP stakeholders, and in the PDSA process. Some mentors were however unsure if they were helping the facilitators in their role as they did not have the experience of facilitating local groups.
There was a shortage of resources, both in the clinical practice and the facilitation process. Medicines, equipment, and staff, e.g., obstetricians and paediatricians, were scarce. In the facilitation process, there was some lack of material for the facilitators. Further, there were insufficient resources for travelling, material to attract people to meetings, suitable venues and communication materials, such as photos, videos, and illustrations.
Many conflicting traditions and norms existed in the study area. For example, men generally made decisions for women and were in charge of the family’s money. There were traditions related to pregnancy and childbirth with adverse health consequences for pregnant women and their newborns. In Cao Bang, many minority groups exist, and as with any group with long-standing and culturally anchored traditions, there was a reluctance to change. Another obstacle was hesitance among females belonging to ethnic minority groups to discuss reproductive health with male PeriKIP stakeholders. Some women in the PeriKIP groups considered travelling in remote areas dangerous, as there was a risk of being robbed.
There were geographic barriers to seeking care. The distance was also difficult for monthly meetings and implementing activities in remote areas. There were also language barriers to the communication with minority groups in Cao Bang.
Relevance of problems and actions
There were 416 prioritised problems at commune level, of which 96% were perceived as relevant, while at the hospital level, there were 88 prioritised problems, and all were perceived as relevant. Table 3 presents the most common problems.
[Table 3 here]
The hospital groups worked with more problems than the commune groups (Table 4). Most problems identified on both levels were addressed by full PDSA cycles.
[Table 4 here]
Knowledge assessment and perspectives of gaining knowledge
Out of the 190 health care workers that completed the knowledge assessment before and after the intervention, there were 92 doctors, 55 midwives and 43 nurses. The respondents were working at commune health centres (n=131) and hospitals (n=59). Overall, the health workers increased their mean knowledge score from 10.8 before the intervention to 11.6 after the intervention (p<0.05) of a maximum score of 22. Nurses increased their mean score with 1.2 (p<0.05) and doctors with 0.8 (p<0.05), while midwives increased their mean score with 0.4 (p=0.19). Health care workers at the commune health centres increased their mean score with 0.7 (p<0.05) and health care staff at hospitals with 0.9 (p<0.05).
Gaining knowledge and insight was a category from the qualitative analysis. Recipients highlighted an increased need of knowledge among health care workers in a large number of areas, including various clinical skills, communication and understanding of the situation in the communes. Participating in the social innovation provided opportunities to learn from each other. Also, participation in PeriKIP made health workers realise the importance of their work and that change was possible.
Observations of antenatal care
Four observations were conducted in each of the 48 communes before and after the social innovation. The mean score increased in seven out of eight domains with 0.3 – 4.3 (p<0.05). Only the domain dealing with recording patient information did not change (Table 5).
[Table 5 here]