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Table 6 Synthesis of implementer groups’ perception of factors influencing implementation: Comparison of Upper and Lower Province Sites

From: Toward communities as systems: a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in Nampula Province, Mozambique

  Upper Province   Lower Province  
Contextual Factors Community-based Implementers perspective Facility-based Implementers perspective Alignment Community-based Implementers perspective Facility-based Implementers perspective Alignment
Adaptability Relevant and valued. TBAs described adaptability between their own and nurse’s roles and responsibilities (e.g. sharing attendance responsibilities during periods of high client volume). TBAs saw this as facilitating implementation. Relevant and valued. Facility staff described adaptability in roles, with TBAs attending to clients during deliveries. Staff valued TBAs’ collaboration to cover client demand, discussing their work as improving client experience. Y Relevant though necessary due to flawed implementation/ imbalance in workload. TBAs discussed adaptability in roles and responsibilities with facility staff in order to cover client demand. TBAs valued adaptability as a factor enabling sustained implementation, but resented the need for it and attributed this need to perceived poor performance of facility staff. Relevant and valued. Facility staff shared examples of adaptability in roles with TBAs for birth attendance, and perceived this as a positive factor in implementation. N
Patient Needs & Resources Valued and perceived as met sufficiently. Community-based implementers described the intervention as responsive to patients’ needs, citing examples of patients’ pleasure with the quality and experience of childbirth in the facility and improved outcomes as compared to previous experiences with home birth. Valued and perceived as met sufficiently. Facility-based implementers described the intervention as responsive to patients’ needs, citing examples of patients’ pleasure with the quality and experience of childbirth in the facility and improved client experience as compared to previous experiences when TBAs, male partners, and family members were not involved in facility birth processes. Y Valued but perceived as inconsistently met. Community-based implementers discussed the intervention as responsive to beneficiaries’ health and emotional needs, and felt this was an important factor. However, TBAs expressed difficulty in ensuring patient needs were met due to examples of disrespectful care and absenteeism on the part of facility staff. These examples were echoed in beneficiary accounts. Valued and perceived as met sufficiently. Facility staff expressed sentiment that patients’ emotional and medical needs were being consistently met by the intervention, attributing this to all implementers. N
Networks & Communications; Knowledge & Beliefs about the Intervention Critical facilitator. Community-based implementers perceived TBAs, nurses, and health facility personnel as having a strong network and effective communication, which they believed benefited their ability to serve beneficiaries. Respondents valued the support they felt from one and another across community and facility settings. Critical facilitator. Facility-based implementers perceived TBAs, nurses, and health facility personnel as having a strong network that supported effective implementation, sharing examples of how they have learned from community colleagues about how to improve beneficiaries’ comfort and experience in facility-based births. Y Critical but dysfunctional. TBAs perceived an unequal distribution of work, due to facility staff absences and disrespectful practices toward TBAs and beneficiaries. By contrast, TBAs and CLC respondents perceived themselves to work in a highly functional network that facilitated their implementation of the intervention. Critical facilitator. Facility staff felt that the network between community- and facility-based implementers was important, positive, and a strong facilitator of implementation. N
Compatibility & Formally Appointed Leaders Valued, facilitating implementation. Community-based implementers described CLCs and TBAs as key influencers and/or gatekeepers in the community, sharing examples of how this aligned with roles in the intervention, and could be leveraged to sustain implementation and community adherence to institutional deliveries. Valued, facilitating implementation. Facility-based implementers recognized their own leadership as medical experts, and also discussed the high level of influence TBAs and CLC members have in setting and enforcing community norms. This was perceived as driving institutional deliveries adherence within the community. Y Valued, facilitating implementation. Community-based implementers described their ability to leverage their established social stature to organize and track community adherence to institutional deliveries, and similarly saw alignment between facility staff’s intervention roles and their existing medical expertise. This compatibility was perceived as a positive factor in their ability to implement. Valued, facilitating implementation. Facility-based implementers recognized their own leadership as medical experts, and also discussed the high level of influence TBAs and CLC members have in setting and enforcing community norms. This was perceived as driving institutional deliveries adherence within the community. Y
Individual Stage of Change Committed to sustaining the intervention. Community-based implementers demonstrate their commitment to implementation, even in the face of physical discomfort (injury) and lack of recognition of their efforts. They discuss their work as permanent practice. Committed to sustaining the intervention.
Facility-based implementers discuss their new partnership with community implementers as critical and share intention to sustain joint implementation into the future.
Y Committed though concerned.
Community-based implementers express personal commitment to their work, even in the face of adversity. However, TBAs and CLC implementers voiced concern that facility implementers do not show the same level of commitment to the intervention, with resulting harmful effects on sustainability.
Committed to sustaining the intervention.
Facility-based implementers express a positive view of their new partnership with community implementers, discussing it as a permanent part of their work now.
N