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PLoS One. 2018 Dec 19;13(12):e0209092. doi: 10.1371/journal.pone.0209092. eCollection 2018.

Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework.

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Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
Department of Public Health Sciences, Global Health-Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden.
Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden.
Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania.
Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom.
Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden.
Makerere School of Public Health, Kampala, Uganda.
UNICEF, Health Section, Programme Division, New York, United States of America.
Institute for Global Health, University College London, London, United Kingdom.



Quality Improvement (QI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect.


A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARIHS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes.


Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention's comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge.


Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.

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