Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial

Cumbe, Vasco; Muanido, Alberto; Turner, Morgan; Ramiro, Isaías; Sherr, Kenneth; Weiner, Bryan J.; Flaherty, Brian P.; Faduque, Flávia; Xerinda, Ernesto Rodrigo; Wagenaar, Bradley H.

doi:10.1186/s13012-022-01213-8

Cited by 10 publications

(8 citation statements)

References 86 publications

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“…Our current work aims to facilitate future adaptations while maintaining reproducibility. Specific work exploring mechanisms of action (and the relative contributions of individual components of SAIA) is underway and will build upon the generalizability of the SAIA, including through the use of longitudinal structural equation modeling [ 36 ].…”

Section: Discussionmentioning

confidence: 99%

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health

Gimbel

Ásbjörnsdóttir

Banek

et al. 2023

Implement Sci Commun

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Background Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its mechanisms of action. Methods Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects. Results Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process. Conclusions Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

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Section: Discussionmentioning

confidence: 99%

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health

Gimbel

Ásbjörnsdóttir

Banek

et al. 2023

Implement Sci Commun

Self Cite

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“…Our review also identified several protocols of trials that will assess the cost-effectiveness of different implementation strategies to scale-up task-shifting interventions for mental health disorders in sub-Saharan Africa. 27 , 28 …”

Section: Discussionmentioning

confidence: 99%

Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation

Yanguela,

Pence,

Udedi

et al. 2024

The Lancet Global Health

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“…The SAIA-SCALE study, testing SAIA for PMTCT services in Mozambique, measured fidelity through a tablet-based survey completed by clinic staff to track number of SAIA cycles, attendants at each cycle meeting, and the number, content, and results of micro-interventions tested [ 33 ]. Two additional studies in Mozambique using SAIA for hypertension and mental health services assessed fidelity as number and frequency of SAIA cycles completed [ 10 ] and adherence to the 5-step SAIA cycle [ 34 ]. All three studies then categorized clinics as high or low performing and used focus group data to assess features of successful implementation.…”

Section: Discussionmentioning

confidence: 99%

Assessing the sustainability of the Systems Analysis and Improvement Approach to increase HIV testing in family planning clinics in Mombasa, Kenya: results of a cluster randomized trial

et al. 2022

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Background In Kenya, HIV incidence is highest among reproductive-age women. A key HIV mitigation strategy is the integration of HIV testing and counseling (HTC) into family planning services, but successful integration remains problematic. We conducted a cluster-randomized trial using the Systems Analysis and Improvement Approach (SAIA) to identify and address bottlenecks in HTC integration in family planning clinics in Mombasa County, Kenya. This trial (1) assessed the efficacy of this approach and (2) examined if SAIA could be sustainably incorporated into the Department of Health Services (DOHS) programmatic activities. In Stage 1, SAIA was effective at increasing HTC uptake. Here, we present Stage 2, which assessed if SAIA delivery would be sustained when implemented by the Mombasa County DOHS and if high HTC performance would continue to be observed. Methods Twenty-four family planning clinics in Mombasa County were randomized to either the SAIA implementation strategy or standard care. In Stage 1, the study staff conducted all study activities. In Stage 2, we transitioned SAIA implementation to DOHS staff and compared HTC in the intervention versus control clinics 1-year post-transition. Study staff provided training and minimal support to DOHS implementers and collected quarterly HTC outcome data. Interviews were conducted with family planning clinic staff to assess barriers and facilitators to sustaining HTC delivery. Results Only 39% (56/144) of planned SAIA visits were completed, largely due to the COVID-19 pandemic and a prolonged healthcare worker strike. In the final study quarter, 81.6% (160/196) of new clients at intervention facilities received HIV counseling, compared to 22.4% (55/245) in control facilities (prevalence rate ratio [PRR]=3.64, 95% confidence interval [CI]=2.68–4.94). HIV testing was conducted with 60.5% (118/195) of new family planning clients in intervention clinics, compared to 18.8% (45/240) in control clinics (PRR=3.23, 95% CI=2.29–4.55). Interviews with family planning clinic staff suggested institutionalization contributed to sustained HTC delivery, facilitated by low implementation strategy complexity and continued oversight. Conclusions Intervention clinics demonstrated sustained improvement in HTC after SAIA was transitioned to DOHS leadership despite wide-scale healthcare disruptions and incomplete delivery of the implementation strategy. These findings suggest that system interventions may be sustained when integrated into DOHS programmatic activities. Trial registration ClinicalTrials.gov (NCT02994355) registered on 16 December 2016.

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Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial

Cited by 10 publications

References 86 publications

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health

Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation

Assessing the sustainability of the Systems Analysis and Improvement Approach to increase HIV testing in family planning clinics in Mombasa, Kenya: results of a cluster randomized trial

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