Background
In efforts at reducing under-five-year-old mortality, it has become evident that both women’s and children’s health need to be focused on along a continuum of care [
1]. A particularly important period is around the time of delivery. Currently, 2.8 million deaths occur worldwide during the neonatal period (the first 28 days after delivery), corresponding to 44 % of under-five-year-old deaths [
2]. Fortunately, available evidence-based interventions exist that can help avoid three out of four neonatal deaths [
3,
4]. The best method of implementation of these interventions in a sustainable way is still unclear.
Facilitation is a knowledge translation approach, whereby one person (the facilitator), using an active and dynamic working strategy, helps and enables a group of people through a developing and learning process [
5]. A group working together with a facilitator could be viewed as a coalition, i.e., a partnership aiming at change and the introduction of innovative solutions to health problems [
6]. Hence, facilitation is a team effort [
7,
8]. Reviews of the facilitation method [
5,
8,
9] unanimously conclude that it is a promising knowledge translation method. Even though some recent studies contribute to increased comprehension of the concept and role of facilitation [
10‐
13], there is still a need of more knowledge from different contexts as to what attributes and skills a facilitator should possess, how to train and support facilitators and the impact of facilitation in knowledge translation [
5,
8,
9,
11].
During the past decade or so, there has been an increased focus on knowledge translation interventions in low- and middle-income countries using empowerment and participation at the community level to increase neonatal survival [
14‐
16]. In Nepal, a groundbreaking study was conducted in which facilitators targeted women’s groups [
17]. In that study, women were facilitated to identify and formulate actions to address perinatal problems, resulting in a reduction in neonatal mortality rate of 30 % and increased coverage of antenatal care, institutional deliveries, skilled birth attendance and hygienic care. Replications of the Nepalese study in South Asia and Africa have also been successful [
18,
19].However, the reduction in neonatal mortality is limited with this approach when trying to cover larger populations [
20].
Inspired by the study in Nepal, our research team conducted the Neonatal Health – Knowledge Into Practice trial (NeoKIP, trial registration ISRCTN44599712) for 3 years in a northern province of Vietnam. This trial investigated the effectiveness of facilitation as a knowledge translation intervention for improving neonatal health and survival [
21]. The intervention resulted in increased attendance to antenatal care clinics and reduced neonatal mortality (adjusted odds ratio 0.51; 95 % confidence interval, 0.30–0.89) after a latent period [
22]. In contrast with the trials targeting women’s groups [
18,
19], we decided to compose groups consisting of local healthcare staff and local key stakeholders, i.e., trained professionals and influential commune members. These (intervention) groups were called maternal and newborn health groups (MNHGs). Facilitators were recruited from the Women’s Union, a social and national governmental organization that predominantly works with issues related to women’s needs (e.g., women’s rights and sexual equality). The facilitators supported the MNHGs through monthly meetings [
23]. We assumed that by including people who were already responsible for health matters, the sustainability of the approach would increase. The intention of the NeoKIP intervention was: (1) training facilitators to use a problem-solving, participatory and enabling approach; (2) empowering and supporting MNHG members to identify local problems and actions in their communes in relation to neonatal health; (3) resulting in improved health outcomes for neonates. This was a complex and multifaceted intervention, including trainers, facilitators, supervisors, MNHG members and community members. The NeoKIP trial was inspired by the Promoting Action on Research Implementation in Health Services framework, which states that successful uptake of evidence into practice is a function of context, evidence and facilitation [
24]. In the NeoKIP trial, we evaluated the effect of facilitation (i.e., facilitators supporting MNHGs) on neonatal mortality, knowing that robust research evidence was available regarding best practice for neonatal care in the Vietnamese healthcare context.
Public health interventions are often implemented without evaluation of the process [
25], although this can give valuable guidance while running the project and in providing explanations on its outcomes [
26,
27]. According to the UK Medical Research Council [
28], the key functions for a process evaluation of complex interventions are to understand: (1) the implementation of the intervention (how it is delivered and what is delivered); (2) the mechanism of impact (what are the participants’ responses to and interactions with the intervention); and (3) whether context affects the implementation and outcomes. Previously we have explored the experiences of facilitators and MNHG members regarding the facilitation intervention [
29] and the influence of context [
30]. In these studies, it was recognized that the MNHGs had a good mix of people and that using a coalition of a facilitator, healthcare staff and key persons was perceived to be a slow process but would have a positive impact on both MNHG members and the public if the involved stakeholders were able to collaborate. Furthermore, this type of intervention was perceived to preferably target disadvantaged groups in society. In this paper, we will present aspects of a process evaluation focusing on the implementation and the mechanisms of impact, aiding comprehension of the results of the trial, particularly the reduction on neonatal mortality in intervention communes.
Results
Implementation
Two individuals from the Women’s Union were recruited to pilot the facilitation role in 2007. They were trained for two days to gain the basic knowledge and skills required to take on this new role, followed by two days of practical work in commune groups. The training was conducted in English by two Swedish researchers (LE and LW), who are familiar with the facilitation technique, and one Vietnamese researcher (NTN), who simultaneously translated the instructions into Vietnamese. The four pilot days indicated a promising potential in having Women’s Union members as facilitators. In addition, the pilot pointed to the need to increase the length of the training and to maintain a continuous support system for the facilitators during the intervention period.
Facilitators were recruited in collaboration with the Women’s Union. Initially, local newspapers advertised the facilitator positions and then each commune was asked to suggest suitable applicants. Thereafter, the Women’s Union office in each of the eight study districts selected two individuals among the applicants for further interviews. Recruitment criteria included being an experienced Women’s Union member, having completed secondary school and having children. Hence, two NeoKIP researchers (NTN and TQH) and the chairwoman of the Women’s Union in Quang Ninh province interviewed 16 potential facilitators. Eight of the potential facilitators were selected for further training. These women were trained for 10 days by means of theoretical sessions, group discussions and role-play activities. Topics focused on during the training programme included group dynamics and quality improvement methods (e.g., brainstorming, the nominal group technique, the plan-do-study-act cycle, and the strengths-weaknesses-opportunities-threats diagnostic tool). To facilitate discussions about neonatal care, the facilitators were introduced to basic evidence-based neonatal care in accordance with the recommendations in the National Guidelines of Reproductive Health Care [
32]. They were also briefed on the current health situation in the province and the function of the healthcare system in relation to reproductive health. The Swedish and Vietnamese researchers jointly developed a ‘facilitation manual’ to guide the facilitators’ daily work. This manual, which provided information on the NeoKIP facilitator role, group dynamics, different tools to use in the facilitation work and basic evidence-based neonatal care, was introduced during the facilitator training period. At the end of the training programme, the eight Women’s Union members practised their skills in rural communes outside the study area. Those practical sessions were followed up by group discussions in which researchers and co-facilitators gave feedback to individual facilitators on their performance. The training was conducted in Vietnamese by two NeoKIP researchers (TQH and NTN). Two Swedish researchers (LE and LW) were also available throughout the training period to assist when needed. The 44 intervention communes were divided between the eight facilitators based on the facilitators’ places of residence and how confident they were in the facilitator role. This division meant that each facilitator worked with five to eight MNHGs on a continuous basis.
The NeoKIP project was firmly established at different levels in the healthcare system. At joint functions, leaders from the various organizations agreed on the implementation of the intervention and were informed of the randomization outcome, i.e. which communes were randomized to be in the intervention arm and which to be in the control arm. The Provincial Health Bureau in Quang Ninh played an important role in assisting NeoKIP researchers in the process of establishing MNHGs in each of the 44 intervention communes. Each of these groups consisted of the vice chairperson of the people’s committee (i.e. the person responsible for education and health in the commune), three members of staff from the community health centre, one community health worker and a Women’s Union representative from the commune or village. In addition to these seven group members, a population collaborator (responsible for collecting population data and performing family planning) was included in the MNHG. The MNHG representatives from the village level (Women’s Union members and community health workers) were selected internally by each organization. Members selected to participate in a MNHG were encouraged to share their experiences with other members of their organizations throughout the intervention period. Meetings and actions conducted within the NeoKIP project were considered to be integrated into the MNHG members’ normal work routine and thus none of the MNHG members was paid additionally for participating in NeoKIP. Two members of the MNHG, the community health worker and the Women’s Union worker from the village level, were reimbursed their travel expenses to and from the MNHG meetings.
Of the initial eight facilitators, four worked during the whole intervention period and four left their positions after approximately 18 months because of other job opportunities (n = 2) or pregnancy (n = 2) and were replaced by three other Women’s Union members. Recruitment and training procedures were similar for all 11 facilitators. However, in connection with the training period, the three last-recruited facilitators worked alongside the four leaving facilitators for one month to become familiar with the facilitator role and introduced to the MNHGs. All facilitators who fulfilled the training programme received a contract that entitled them to a monthly salary when working as a facilitator. The 11 facilitators (nine Kinh people and two from the Tay ethnic minority group) had a mean age of 32 years at recruitment.
Two research team members (TQH and DMD) acted as supervisors of the facilitators throughout the intervention period; i.e., they supported the facilitators and assisted and coordinated the facilitation process, primarily by having monthly meetings with the facilitators and through field support. During the intervention period, 35 monthly meetings with supervisors and facilitators took place. From meeting records, we have identified the monthly meetings as an important forum for clarifying, discussing and developing the facilitator role, as well as for discussing the facilitation process and reporting on MNHGs actions. The facilitators were also continuously educated about basic evidence-based neonatal care at these support meetings, as they often requested additional information related to clinical issues and perceived such knowledge to be essential for achieving successful outcomes. Further, the facilitation diary was continuously developed to better serve as a tool for the facilitators. Supervisors and co-facilitators also attended MNHG meetings to observe and give constructive criticism to the facilitator in charge. Field support decreased over time, as the facilitators became more secure in their roles (Table
2).
Table 2
Data on meetings and support during the intervention period
MNHG meetings | 474 | 90 | 520 | 98 | 514 | 97 | 1508 | 95 |
Facilitator joined MNHG activity in a commune | 68 | – | 166 | – | 60 | – | 294 | – |
Facilitator supported a co-facilitator at a MNHG meeting | 102 | 22 | 11 | 2 | 9 | 2 | 122 | 8 |
NeoKIP researcher supported a facilitator at a MNHG meeting | 53 | 11 | 25 | 5 | 18 | 4 | 96 | 6 |
Monthly meetings between supervisors and facilitators | 11 | 92 | 12 | 100 | 12 | 100 | 35 | 97 |
The primary working tools used by the facilitators were the brainstorming technique and the plan-do-study-act cycle. A MNHG meeting with a facilitator lasted on average 110 minutes. In addition to facilitating MNHG meetings, the facilitators joined the intervention groups while implementing actions in the commune between meetings. During the implementation of actions, the facilitators took on different tasks. On some occasions, the facilitators were active in implementing an action together with the members of the MNHG while on other occasions they observed the group implementing those actions. Sometimes the facilitators assessed whether an action had been executed with the desired effect. For example, when messages were communicated at a meeting, the facilitators asked the assembled commune members if they understood and appreciated the delivered messages. Such activities occurred most frequently during the second year of the intervention (Table
2).
In total, 95 % (1508/1584) of the planned meetings with a MNHG and a facilitator were completed during the 3-year intervention (Table
2). The main reason for cancelled meetings in the first year was the difficulties in getting MNHGs organized for their first meeting. Although the intervention started in July, some MNHGs did not have their first meeting until November. After resolving this initial problem, most of the groups met regularly. In addition to the initial problem, the most common cause preventing the facilitator from assembling the MNHG during the intervention period was poor weather conditions, which mainly affected groups in mountainous and remote communes. Among the 44 MNHGs, 20 groups had the same facilitator throughout the intervention period, 22 groups changed facilitators once and 2 groups changed facilitators twice. One city-based MNHG that changed facilitators twice ceased activities in April 2010 because the group members did not believe in the project.
In total, 388 individuals served as MNHG members and participated during an average of 31 months in the NeoKIP intervention (Table
3). The overall meeting attendance among MNHG members was 86 %. Members with the highest attendance at these meetings were the head of the Women’s Union at village level, the head of the community health centre and the midwife. The vice chairperson of the peoples committee, also acting as the chair in most MNHGs, participated in approximately two-thirds of the meetings (61 %).
Table 3
Basic data on MNHGs and members’ attendance
Basic data | 44 MNHGs |
Number of participants | 388 |
Mean time participating in the NeoKIP project (months) | 31 |
Mean Age (years) | 42 |
Proportion females (%) | 76 |
Proportion belonging to Kinh group (%) | 71 |
Attendance (%) | 44 MNHGs |
Overall | 86 |
Head of Women’s Union (village level) | 97 |
Head of community health centre | 95 |
Midwife | 94 |
Community health worker | 90 |
Nurse | 88 |
Population collaborator (commune level) | 87 |
Chairwoman of Women’s Union (commune level) | 87 |
Vice chairperson of peoples committee | 61 |
Mechanisms of impact
Altogether, the 44 MNHGs identified 32 types of problem and implemented 39 types of action (Table
4 and Additional file
3). More problems and actions were identified and implemented during the first intervention year, while the number of problems and actions declined during the second and third years. Overall, the most frequently identified problems were ‘low frequency of antenatal visits at the right time’, ‘low frequency of postnatal home visits’, ‘low awareness among pregnant women of appropriate diet, work and rest’, ‘high frequency of home deliveries’ and ‘low awareness among pregnant women about appropriate breastfeeding practices’. During the first year of the intervention, the MNHGs mostly identified problems addressing the pregnant women’s behaviour, knowledge and health (Table
4). Across the intervention period, the focus shifted such that the MNHGs were equally targeting health issues for pregnant women and for neonates.
Table 4
Identified problems and implemented actions among 44 maternal and newborn health groups for individual intervention years and the entire intervention period
Problems | Number of unique problems (n) | 27 | 20 | 15 | 32 |
Total number of times unique problems were identified (n) | 151 | 135 | 94 | 206 |
Five most commonly identified problems (n)a | Low frequency of antenatal visits at the right time (30) | Low frequency of antenatal visits at the right time (39) | Low frequency of antenatal visits at the right time (33) | Low frequency of antenatal visits at the right time (42) |
Low frequency of postnatal home visits (24) | Low frequency of postnatal home visits (28) | Low frequency of postnatal home visits (26) | Low frequency of postnatal home visits (33) |
Little awareness among pregnant women of appropriate diet regime, work and rest (20) | High frequency of home deliveries (14) | High frequency of home deliveries (14) | Little awareness among pregnant women of appropriate diet, work and rest (23) |
Little awareness among pregnant women of antenatal care (13) | Little awareness among pregnant women of appropriate diet regime, work and rest (12) | Low rate of exclusive breastfeeding (7) | High frequency of home deliveries (16) |
Little awareness among pregnant women of appropriate breastfeeding practices (10) | Low rate of exclusive breastfeeding (9) | Little awareness among pregnant women about appropriate breastfeeding practices (2) Little awareness among pregnant women about appropriate diet regime, work and rest (2) Low rate of tetanus vaccination (2) | Little awareness among pregnant women of appropriate breastfeeding practices (14) |
Actions | Number of unique actions (n) | 25 | 27 | 19 | 39 |
Total number of times unique actions were implemented (n) | 649 | 511 | 297 | 933 |
Five most commonly implemented actions (n)a | Counselling at community health centre (123) | Counsel and mobilize women at their home (108) | Counsel and mobilize women at their home (72) | Counsel and mobilize women at their home (170) |
Communication at community meetings (115) | Communication at community meetings (105) | Communication at community meetings (65) | Communication at community meetings (168) |
Counsel and mobilize women at their home (108) | Counselling at community health centre (98) | Counselling at community health centre (60) | Counselling at community health centre (164) |
Communication through loudspeakers (83) | Communication through loudspeakers (61) | Postnatal home visits (41) | Communication through loudspeakers (105) |
Write communication papers (68) | Postnatal home visits (44) | Communication through loudspeakers (33) | Write communication papers (68) |
Actions taken mainly concerned the dissemination of health information in diverse ways and forums (Table
4 and Additional file
3). The most common communication methods were ‘counselling and mobilizing women at home’, ‘communication at community meetings’, ‘counselling women at community health centres’ and ‘communicating messages through village loudspeakers’. Health information messages were produced by all 44 MNHGs, primarily compiled by the midwives in the MNHGs. The content addressed identified problems and most often adhered to the recommendations in the practice guidelines for reproductive healthcare [
32]. However, these messages were sometimes on a more general level instead of giving specific guidance on how to deal with certain health problems. For instance, if low awareness of breastfeeding practices was identified as a problem, some groups would only inform mothers of the benefits of breastfeeding, whereas those providing specific information would also give instructions on how to breastfeed the child. When MNHG members communicated their messages, they used existing forums in the commune (Additional file
3). The person responsible for communication was often related to the type of meeting, i.e. a Women’s Union representative was the communicator at a Women’s Union meeting and the midwife was the communicator at the reproductive health day (Additional file
3).
The score of the 11 facilitators in the assessment of attributes and skills ranged from 0 to 1.0 (median 0.58) using method 1 and from 0.14 to 0.81 (median 0.56) using method 2. The weighted kappa for the six items in the scale ranged from 0.36 to 0.69. The neonatal mortality rate for the third year of the NeoKIP trial was lower in both ‘low facilitator communes’ (17.1/1,000) and ‘high facilitator communes’ (8.5/1,000) than in ‘control communes’ (21.1/1,000) (Table
5). However, it was only ‘high facilitator communes’ that had a significantly lower odds ratio of neonatal mortality (odds ratio, 0.37 [95 % confidence interval, 0.19–0.73]).
Table 5
Neonatal mortality rates and odds ratios on neonatal mortality for communes supported in ‘high facilitator’, ‘low facilitator’ or control communes during the third year in the NeoKIP trial
Number of communes | 27 | 17 | 46 |
Live births | 2597 | 1461 | 3695 |
Neonatal deaths | 22 | 25 | 78 |
Neonatal deaths / 1,000 live births (95 % confidence interval) | 8.5 (5.3–12.8) | 17.1 (11.1–25.2) | 21.1 (16.7–26.3) |
Odds ratio (95 % confidence interval)b | 0.37 (0.19–0.73) | 0.75 (0.38–1.48) | 1 |
Competing interests
The authors declare that they have no competing interest.
Authors’ contributions
LW, LE and TQH designed the intervention. TQH and DMD were responsible for training and supervision of facilitators, with assistance from NTN, DPH and NTT. LE and LW designed the process evaluation. KES, LE, LW and LÅP analyzed data. LE drafted the manuscript with assistance from LW. All authors have read and approved the final manuscript.