title: The prevention of mother-to-child transmission of HIV cascade analysis tool: supporting health managers to improve facility-level service delivery.
abstract: BACKGROUND
  The objective of the prevention of Mother-to-Child Transmission (pMTCT) cascade analysis tool is to provide frontline health managers at the facility level with the means to rapidly, independently and quantitatively track patient flows through the pMTCT cascade, and readily identify priority areas for clinic-level improvement interventions. Over a period of six months, five experienced maternal-child health managers and researchers iteratively adapted and tested this systems analysis tool for pMTCT services. They prioritized components of the pMTCT cascade for inclusion, disseminated multiple versions to 27 health managers and piloted it in five facilities. Process mapping techniques were used to chart PMTCT cascade steps in these five facilities, to document antenatal care attendance, HIV testing and counseling, provision of prophylactic anti-retrovirals, safe delivery, safe infant feeding, infant follow-up including HIV testing, and family planning, in order to obtain site-specific knowledge of service delivery.
  
  
  RESULTS
  Seven pMTCT cascade steps were included in the Excel-based final tool. Prevalence calculations were incorporated as sub-headings under relevant steps. Cells not requiring data inputs were locked, wording was simplified and stepwise drop-offs and maximization functions were included at key steps along the cascade. While the drop off function allows health workers to rapidly assess how many patients were lost at each step, the maximization function details the additional people served if only one step improves to 100% capacity while others stay constant.
  
  
  CONCLUSIONS
  Our experience suggests that adaptation of a cascade analysis tool for facility-level pMTCT services is feasible and appropriate as a starting point for discussions of where to implement improvement strategies. The resulting tool facilitates the engagement of frontline health workers and managers who fill out, interpret, apply the tool, and then follow up with quality improvement activities. Research on adoption, interpretation, and sustainability of this pMTCT cascade analysis tool by frontline health managers is needed.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT02023658, December 9, 2013.
authors.affiliation: Department of Family Child Nursing, University of Washington, Box 357262, Seattle, USA. sgimbel@uw.edu.
authors.forename: Sarah
authors.initials: S
authors.lastname: Gimbel
authors.forename: Joachim
authors.initials: J
authors.lastname: Voss
authors.forename: Mary Anne
authors.initials: MA
authors.lastname: Mercer
authors.forename: Brenda
authors.initials: B
authors.lastname: Zierler
authors.forename: Stephen
authors.initials: S
authors.lastname: Gloyd
authors.forename: Maria de Joana
authors.initials: Mde J
authors.lastname: Coutinho
authors.forename: Florencia
authors.initials: F
authors.lastname: Floriano
authors.forename: Maria de Fatima
authors.initials: Mde F
authors.lastname: Cuembelo
authors.forename: Jennifer
authors.initials: J
authors.lastname: Einberg
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
mesh_terms: D002648:Child; D003695:Delivery of Health Care / Q000379:methods* / Q000592:standards; D005260:Female; D005843:Geography; D015658:HIV Infections / Q000517:prevention & control*; D006268:Health Facilities / Q000592:standards*; D006282:Health Personnel; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D009035:Mothers; D009073:Mozambique; D011181:Postnatal Care; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000517:prevention & control*