Addressing Behavior Change in Maternal, Neonatal, and Child Health with Quality Improvement and Collaborative Learning Methods in Guatemala

"...they decided to follow a major QI [quality improvement] principle: Always involve in the improvement effort those who directly perform the process, in whole or in part."

This book chapter describes how two projects in Guatemala, both funded by the United States Agency for International Development (USAID), applied quality improvement (QI) principles and methods to social and behaviour change communication (SBCC) interventions. QI has been mostly associated with improving clinical care, where teams review medical records to determine whether caregivers complied with care quality criteria and then suggest and test process changes to address gaps. In the case of the projects described here, leaders and stakeholders were convinced that QI elements, such as the plan-do-study-act (PDSA) cycle and collaborative learning methods, could also work to improve SBCC interventions.

As the chapter recounts, after a first community-based collaborative proved critical in effecting changes to maternal health knowledge and practices in a demonstration area, the project introduced, in 2012, a second community-based collaborative in 166 health posts and 429 community centres. The initiative focused on improving processes of care and nutritional results during the first 1,000 days of life (from pregnancy to the child's second birthday) to improve the effectiveness of interpersonal communication and counseling and other SBCC strategies to increase the health knowledge of women and their families and achieve change in 19 health- and nutrition-related behaviours.

To generate interest in expanding the QI collaborative's focus on SBCC for maternal, neonatal, and child health (MNCH), the project initially used a local advocacy approach. Project leaders worked with social workers, rural health technicians, and health educators from the Ministry of Health (MOH) Health Promotion and Education Department to explain how information and data on health promotion activities and behavioural outcomes was critical to improving their ability to communicate with and interact with clients in the community. Further, they sought to demonstrate how the QI methods being used to improve clinical health care could be used to improve community SBCC. To garner buy-in from the central-level MOH, the project invited the authorities to the health districts' quarterly learning sessions. Reprotedly, support for using improvement methods to strengthen SBCC messaging and campaigns grew among MOH officials; their advocacy for this work proved critical.

The establishment of the 2012 community collaborative's QI teams was a participatory process, as the chapter explores. Notably, all staff were considered members of the QI team and participated in both clinical and community QI efforts, especially in analysing results and planning changes that would lead to improvement.

Next, based on the available evidence and the health and nutrition situation in Guatemala, the MOH and the SBCC QI collaboratives developed indicators for selected key essential behaviours or practices for families with pregnant women and/or children under 2 years of age. Measuring indicators entailed that, each quarter, a sample of 19 pregnant women or mothers of children 0-2 years of age from each supervision area were selected to interview using Lot Quality Assurance Sampling (LQAS). The project trained the teams in the sampling method, provided the tools, and supervised teams in the selection of households and respondents and the LQAS interview process. The QI team then consolidated and analysed results and identified those indicators that scored lower. Then, they discussed the reasons for low performance and planned changes in SBCC activities to improve results that could be implemented during home visits, health talks, and mass media campaigns.

To plan these changes, the community-based collaboratives initially used tools from the behaviour change field and adapted them for use in QI. For example, the BEHAVE model, which was developed by the Academy for Educational Development, focused health workers on specific actions to convey danger signs to pregnant women. Later, the community collaborative used the standard QI "planning matrix" being used in the clinical health-care collaborative to plan changes and improve results. It contained six columns: (i) gap found, (ii) proposed change, (iii) activities to be conducted, (iv) where, (v) when, and (vi) person responsible for leading the effort.

The chapter provides an example of carrying out the SBCC improvement effort in Chichicastenango, Quiché. The provider behaviour change (PBC) intervention required challenging a perception that traditional birth attendants (TBAs) would be reluctant or unwilling to talk about emergency birth plans with their patients, lest the family think they were incapable of attending women in their homes. Whether or not this perception was valid, the teams knew they had to find a way to get the TBAs to assume ownership of the intervention. The QI team tested the interventions during two quarters by training TBAs, organising guided visits to the appropriate hospital, and meeting with the health commission to discuss the community emergency plan. After this intervention began to yield successful results, the health district continued to actively work with the TBAs to, for example, expand their participation in the referral programme. TBAs with the largest number of referrals at the end of the quarter received a certificate of accomplishment from the health facility.

To measure indicators and identify those that were not reaching the quality targets, the collaborative used LQAS, a relatively low-cost and simple sampling method. Most indicators showed increases after successive QI cycles of measuring, planning, trying out changes, and adopting those that resulted in improvement. Activities community QI teams carried out to achieve these outcomes included developing key messages and talks on the ideal inter-pregnancy interval for use at every clinic visit and during household visits, as well as conducting postpartum exams at home and bringing clinical records to register findings. Also, coaching visits to supervision areas were conducted each quarter for both the clinical and the community-based collaboratives.

Project participants came away with lessons learned about the formation of community QI teams. For example, they found that organisers of QI efforts would be well served to first consider the structure of a country's healthcare system and the number and type of health providers available. In addition, in this primary healthcare setting, clinical and community-based collaboratives had to work together to optimise involvement of the limited number of personnel and achieve results. Project participants also found that it was sometimes critical to challenge existing perceptions when implementing a QI intervention. The QI intervention with TBAs described in this case study required that the team trust that TBAs would be willing and able to assume ownership of the strategy.

Since the project, QI methods and tools have become part of MOH guidelines and are being used by other cooperating agencies and projects. QI methodology has taken root with some health providers who participated in QI efforts and remained in their posts. They continue to use them to measure and improve processes and results, even when, in practice, the central-level MOH does not actively promote and support their use any longer.