title: Evaluation of a quality improvement intervention to prevent mother-to-child transmission of HIV (PMTCT) at Zambia defence force facilities.
abstract: BACKGROUND
  The Zambian Defence Force (ZDF) is working to improve the quality of services to prevent mother-to-child transmission of HIV (PMTCT) at its health facilities. This study evaluates the impact of an intervention that included provider training, supportive supervision, detailed performance standards, repeated assessments of service quality, and task shifting of group education to lay workers.
  
  
  METHODS
  Four ZDF facilities implementing the intervention were matched with four comparison sites. Assessors visited the sites before and after the intervention and completed checklists while observing 387 antenatal care (ANC) consultations and 41 group education sessions. A checklist was used to observe facilities' infrastructure and support systems. Bivariate and multivariate analyses were conducted of findings on provider performance during consultations.
  
  
  RESULTS
  Among 137 women observed during their initial ANC visit, 52% came during the first 20 weeks of pregnancy, but 19% waited until the 28th week or later. Overall scores for providers' PMTCT skills rose from 58% at baseline to 73% at endline (p=0.003) at intervention sites, but remained stable at 52% at comparison sites. Especially large gains were seen at intervention sites in family planning counseling (34% to 75%, p=0.026), HIV testing during return visits (13% to 48%, p=0.034), and HIV/AIDS management during visits that did not include an HIV test (1% to 34%, p=0.004). Overall scores for providers' ANC skills rose from 67% to 74% at intervention sites, but declined from 65% to 59% at comparison sites; neither change was significant in the multivariate analysis. Overall scores for group education rose from 87% to 91% at intervention sites and declined from 78% to 57% at comparison sites. The overall facility readiness score rose from 73% to 88% at intervention sites and from 75% to 82% at comparison sites.
  
  
  CONCLUSIONS
  These findings are relevant to civilian as well as military health systems in Zambia because the two are closely coordinated. Lessons learned include: the ability of detailed performance standards to draw attention to and strengthen areas of weakness; the benefits of training lay workers to take over non-clinical PMTCT tasks; and the need to encourage pregnant women to seek ANC early.
authors.affiliation: Jhpiego/USA, an affiliate of Johns Hopkins University, 1615 Thames Street, Baltimore, MD 21231, USA. Young-Mi.Kim@jhpiego.org.
authors.forename: Young Mi
authors.initials: YM
authors.lastname: Kim
authors.forename: Maureen
authors.initials: M
authors.lastname: Chilila
authors.forename: Hildah
authors.initials: H
authors.lastname: Shasulwe
authors.forename: Joseph
authors.initials: J
authors.lastname: Banda
authors.forename: Webby
authors.initials: W
authors.lastname: Kanjipite
authors.forename: Supriya
authors.initials: S
authors.lastname: Sarkar
authors.forename: Eva
authors.initials: E
authors.lastname: Bazant
authors.forename: Cyndi
authors.initials: C
authors.lastname: Hiner
authors.forename: Maya
authors.initials: M
authors.lastname: Tholandi
authors.forename: Stephanie
authors.initials: S
authors.lastname: Reinhardt
authors.forename: Joyce Chongo
authors.initials: JC
authors.lastname: Mulilo
authors.forename: Adrienne
authors.initials: A
authors.lastname: Kols
mesh_terms: D000293:Adolescent; D000328:Adult; D004502:Education, Medical, Continuing / Q000379:methods; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D058749:Military Facilities / Q000592:standards; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods / Q000592:standards; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D055815:Young Adult; D015024:Zambia