The RE-AIM framework-based evaluation of the implementation of the Maternal and Child Health Handbook program in Angola: a mixed methods study.

BACKGROUND: The World Health Organization recommends the Maternal and Child Health Handbook (MCH-HB) to promote health service utilization from pregnancy to early childhood. Although many countries have adopted it as a national health policy, there is a paucity of research in MCH-HB's implementation. Thus, this study aimed to evaluate the MCH-HB's implementation status based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), and identify facilitators of, and barriers to its implementation in Angola to understand effective implementation strategies. METHODS: A cross-sectional survey was conducted targeting all health facilities which implemented MCH-HB, subsamples of health workers, and officers responsible for the MCH-HB at the municipality health office. Using the 14 indicators based on the RE-AIM framework, health facilities' overall implementation statuses were assessed. This categorized health facilities into optimal-implementation and suboptimal-implementation groups. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews were conducted among health workers and municipality health officers responsible for MCH-HB. The data were analyzed via content analysis. RESULTS: A total of 88 health facilities and 216 health workers were surveyed to evaluate the implementation status, and 155 interviews were conducted among health workers to assess the barriers to and facilitators of the implementation. The overall implementation target was achieved in 50 health facilities (56.8%). The target was achieved by more health facilities in urban than rural areas (urban 68.4%, rural 53.6%) and by more health facilities of higher facility types (hospital 83.3%, health center 59.3%, health post 52.7%). Through the interview data's analysis, facilitators of and barriers to MCH-HB were comprehensively demonstrated. MCH-HB's content advantage was the most widely recognized facilitator and inadequate training for health workers was the most widely recognized barrier. CONCLUSIONS: Strengthening education for health workers, supervision by municipality health officers, and community sensitization were potential implementation strategies. These strategies must be intensified in rural and lower-level health facilities.

The Maternal and Child Health Handbook for Improving the Continuum of Care and Other Maternal and Child Health Indicators in Angola: An Implementation Study Protocol.

Background: Reducing maternal, neonatal, and infant mortality tops the health targets of sustainable development goals. Many lifesaving interventions are being introduced in antenatal, delivery, and postnatal care. However, many low- and middle-income countries (LMICs) have not reached maternal and child health targets. The Maternal and Child Health Handbook (MCH-HB) is recommended as a home-based record to promote a continuum of care from pregnancy to early childhood, and is gaining increasing attention among LMICs. Several countries have adopted it as national health policy. To effectively utilize the MCH-HB in LMICs, implementation needs to be considered. Angola is an LIMC in Sub-Saharan Africa, where maternal and child health indicators are among the poorest. The Angolan Ministry of Health adopted the MCH-HB program in its national health policy and is currently conducting a cluster randomized controlled trial (MCH-HB RCT) to evaluate its impact on the continuum of care. This study aimed to evaluate implementation status, and barriers and facilitators of MCH-HB program implementation in Angola. Methods: To evaluate implementation status comprehensively, the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework will be used. Four components other than effectiveness will be investigated. A cross-sectional survey will be conducted targeting all health facilities and officers in charge of the MCH-HB at the municipality health office in the intervention group after the MCH-HB RCT. Data from the cross-sectional survey, secondary MCH-HB RCT data, and operational MCH-HB RCT records will be analyzed. Health facilities will be classified into good-implementation and poor-implementation groups using RE-AIM indicators. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews/focus group discussions will be conducted among health workers at a sub-sample of health facilities and all municipality health officers in charge of MCH-HB in the intervention group. The Consolidated Framework for Implementation Research will be adopted to develop interview items. Thematic analysis will be performed. By comparing good-implementation and poor-implementation health facilities, factors that differ between groups that contribute to successful implementation can be identified. Discussion: This study's findings are expected to inform MCH-HB implementation policy and guidelines in Angola and in other countries that plan to adopt the MCH-HB program.