title: Using adapted quality-improvement approaches to strengthen community-based health systems and improve care in high HIV-burden sub-Saharan African countries.
abstract: BACKGROUND
  Achieving long-term retention in HIV care is an important challenge for HIV management and achieving elimination of mother-to-child transmission. Sustainable, affordable strategies are required to achieve this, including strengthening of community-based interventions. Deployment of community-based health workers (CHWs) can improve health outcomes but there is a need to identify systems to support and maintain high-quality performance. Quality-improvement strategies have been successfully implemented to improve quality and coverage of healthcare in facilities and could provide a framework to support community-based interventions.
  
  
  METHODS
  Four community-based quality-improvement projects from South Africa, Malawi and Mozambique are described. Community-based improvement teams linked to the facility-based health system participated in learning networks (modified Breakthrough Series), and used quality-improvement methods to improve process performance. Teams were guided by trained quality mentors who used local data to help nurses and CHWs identify gaps in service provision and test solutions. Learning network participants gathered at intervals to share progress and identify successful strategies for improvement.
  
  
  RESULTS
  CHWs demonstrated understanding of quality-improvement concepts, tools and methods, and implemented quality-improvement projects successfully. Challenges of using quality-improvement approaches in community settings included adapting processes, particularly data reporting, to the education level and first language of community members.
  
  
  CONCLUSIONS
  Quality-improvement techniques can be implemented by CHWs to improve outcomes in community settings but these approaches require adaptation and additional mentoring support to be successful. More research is required to establish the effectiveness of this approach on processes and outcomes of care.
authors.affiliation: aCentre for Rural Health, University of KwaZulu-Natal, Durban, South Africa bInstitute for Healthcare Improvement, Cambridge, Massachusetts, USA cMaiKhanda Trust, Lilongwe, Malawi dUSAID Applying Science to Strengthen and Improve Systems Project, Maryland, USA.
authors.forename: Christiane M
authors.initials: CM
authors.lastname: Horwood
authors.forename: Michele S
authors.initials: MS
authors.lastname: Youngleson
authors.forename: Edward
authors.initials: E
authors.lastname: Moses
authors.forename: Amy F
authors.initials: AF
authors.lastname: Stern
authors.forename: Pierre M
authors.initials: PM
authors.lastname: Barker
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000627:therapeutic use; D003153:Community Health Services / Q000458:organization & administration* / Q000592:standards; D003150:Community Health Workers / Q000458:organization & administration* / Q000592:standards; D003299:Cooperative Behavior; D003625:Data Collection / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy / Q000517:prevention & control* / Q000635:transmission; D007722:Health Knowledge, Attitudes, Practice; D006302:Health Services Research; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D010342:Patient Acceptance of Health Care; D010353:Patient Education as Topic; D016730:Program Development / Q000379:methods*; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration* / Q000592:standards
chemical_list: D019380:Anti-HIV Agents