Understanding the Mechanisms of Change in the Supportive and Respectful Maternity Care Intervention in Sindh, Pakistan: Provider Perspectives

The authors identify ways that a supportive and respectful maternity care intervention was implemented along multiple pathways–and concertedly with various health system components–to enable positive processes and behavioral change in maternity teams.


Intervention component Mechanism Outcome Question Logic
Now I will ask some questions about assessment of participant vulnerabilities.The questions that are asked from participants at the time of admission to screen for any mental condition or disability. 2 Assessment for the vulnerabilities Enable maternity staff to understand the needs of pregnant women to develop care plan Care is provided according to the identified vulnerabilities

Instructions
Now I would like to discuss with you about the Psychosocial support process that you have implemented in your facility.First we will discuss your experience related to each step of psychosocial support process for the patient and then in the subsequent questions we will discuss your experiences related to psychosocial support for staff and then finally we will discuss the overall psychosocial support process for the patient and staff

Instruction for facilitator regarding posters
Participant will be shared the A-4 size print of posters of psychosocial support process that was developed for patient and staff.All steps will be quickly highlighted while mentioning the difference of implementation strategies for patients and staff.(The posters will be helpful for question 1 related to experiences about overall implementation of psychosocial support process for the patient and staff but for rest of the questions (2-8) participants will be referred to the specific section of the poster) Instruction: Now we will talk about reducing stress via breathing exercise which is one of the support strategies and has been implemented in your facility.
Information card: Patients and their companion were guided about breathing exercise.First they were told about the purpose of this exercise that it reduces stress and makes us calm, then they were guided about the way to breathe followed by focusing on their breathing pattern and then finally told to keep practicing it during labour and childbirth, especially whenever feel stressed.4 Reduce stress via breathing exercise Learn systematic skill to reduce stress Patients experience more sense of control and less distress 1.0: Has the breathing excercise been implemented here (if yes, how and if not they why not please give reasons) 1.1: Did you find any change in the care provision after incorporating complete breathing strategy as a support process?Probes; Thank you for consenting to be part of this evaluation.As mentioned, the purpose of this interview is to understand your perspective about different components of SDMC intervention that are being implemented in your health facility.I will start by asking some questions about SDMC training that you had an attended few months ago. 1 What did you like about the SDMC training that was influential in your work?Please give an example.
1.3 In your opinion, how the learnings that you acquired from the SDMC training influenced your work?Probe: For example, the way you deal with your patients or deal with your colleagues?Outcome Outcome Mechanism 1.4 Would you like to propose any changes to the SDMC training?Probe: content, duration, relevance, practicality 1.5 If yes, what changes would you like to suggest to the SDMC training?Probe: content, duration, relevance, practicality 1.6 Please also tell how these proposed changes will help provision of SDMC?
Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities inSindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216Supplementto: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216NowI will ask some questions about a monthly performance review meeting that was introduced in the health facility.We would to understand the impact of these monthly meetings on your work.6 Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216 Mechanism 2.4 Would you like to propose any changes to vulnerability assessment?Probe: reduce questions, add questions, merging with other registers, clear instructions 2.5 If yes, what changes would you like to suggest to vulnerability assessment?Probe: reduce questions, add questions, merging with other registers, clear instructions 2.6 Please also tell how these proposed changes will help provision of SDMC?Outcome 2.7 Would you like to continue with the vulnerability assessment?If so, why would you like this to be continued?If no, why not?Probe: personalised care, brief tools, meeting patient needs 2.8 How can we make the better use of vulnerability assessment in providing SDMC?Outcome Mechanism-outcome Outcome 3.2 In your opinion, were all maternity team adhering to the protocol of ensuring patient respect and dignity?If no, which cadre of staff members were non-adherent?And why? Context 3.3 Under what circumstances, is it difficult for your ensure respect and dignity of pregnant women?And what can be done to address these issues?Probe: I'm asking about scenarios when it was difficult to maintain privacy, taking consent for the procedure, avoid physical or verbal abuse, ineffective communication etc. Context 3.4 What motivates you and others to provide SDMC?Mechanism Mechanism 5.4 Would you like to propose any changes to patient complaint system?Probe: reduce questions, add questions, merging with other registers, clear instructions, external or independent person to document 5.5 If yes, what changes would you like to suggest to patient complaint system?Probe: reduce questions, add questions, merging with other registers, clear instructions, external or independent person to document 5.6 Please also tell how these proposed changes will help provision of SDMC?Mechanism 5.7 Would you like to continue with the patient complaint system?If so, why would you like this to be continued?If no, why not?Probe: ensuring accountability, identify gaps, workload 5.8 How can we make the better use of patient complaint system in providing SDMC?Context Mechanism Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-002166.2If yes, could you explain in detail about those impact?Outcome 6.3 If any, what difficulties were faced in conducting monthly meeting?Probe: workload, reluctance of staff Mechanism 6.4 Would you like to propose any changes to the monthly meeting mechanism?Probe: add more people, reward system, focal person 6.5 If yes, what changes would you like to suggest to the monthly meeting mechanism?Probe: add more people, reward system, focal person 6.6 Please also tell how these proposed changes will help in your work?Mechanism 6.7 Would you like to continue with the monthly meetings?If so, why would you like this to be continued?If no, why not?Probe: ensuring accountability, identify gaps, smoothen processes 6.8 How can we further improve the effectiveness of monthly meetings?Context Mechanism 7.4 How those changes can be implemented that will pave the way for SDMC?
A systematic psychosocial process was implemented for the patients and staff with a purpose to reduce their stress and help them cope with it.1Supplementto:AvanBI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities inSindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216Now we will talk about implementation of psychosocial support in your facility.Information card: Once vulnerability/psychosocial assessment is done.We do the psychosocial care planning whose purpose is to ensure readiness of the patient before delivery.It includes identifying companion or health worker in case of no companion for the patient, encouraging patients to share their needs and reassuring patients regarding support from you and companion.2 Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216 Instruction: Now I finally like know your opinion about overall psychosocial process for patients and also for staff that has been implemented in your facility Information card:-System level: support from heads, support and supervision of MHFA/SDMC officer -staff level: enhanced knowledge and skill, motivation to apply learned skills Patient level: patient satisfaction, increased trust and compliance Outcome 1.2: What were the barriers in implementation of psychosocial support process for patient and staff?Probes:-System level: lack of support from heads, insufficient support and supervision from MHFA/SDMC officer, lack of acknowledgement, increased workload, lack -Staff level: build rapport/ increase trust on health staff, -Patient level: promote patient's autonomy (can decide the companion of her choice), patient feels that she was listened to, clarify misconception, patient feels supported and less lonely -Companion level: support in communication process, reduce patients' distress -Staff level: increase staff's knowledge about psychosocial stressors, their impact and need for support for women, enhance rapport with patient and companion, support/supervision from MHFA/SDMC officer to continue implementation -Patient level: build their knowledge, feel more controlled, clarify misconception, -Companion level: build knowledge, try to support more to reduce patients' distress Outcome 1.2: Did you face any difficulties in implementing psycho-education, if yes probes:-Staff level: time taking process, workload, not encouraged by the heads, psychosocial psychoeducation should be combined with psychoeducation on labour and childbirth -Patient level: emergency situation, patient was not interacting -Companion level: lack of cooperation Mechanism-context 1.3:In your opinion, how this psycho-education for patients be improved Staff level: more support from MHFA/heads, division of workload, Patient and companion level: should be informed about all the steps of psychosocial support and then introduce psycho-education, add importance of why it is needed outcome Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities inSindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216NowIwouldlike to know your opinion about companion engagement in care process which is one of the support strategies and has been implemented in your facility.Information card: Companion engagement is part of strengthening social support, where companion is guided about 10 possible roles that they could play in providing care to the patient during labour and delivery.Its purpose is to provide support from a familiar person which can reduce patient's experience of distress.5Supplementto:AvanBI,HameedW,Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities inSindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216At the time exit after delivery, patient is also guided about different way to enhance their well-being such as engaging in pleasurable activities.Especially companion of those patients who found to have depression or anxiety based on vulnerability screening are also guided to keep supporting the patient at home as well.6Supplementto:AvanBI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216NowIwould like to know your opinion about referral process that has been implemented in your facility for patients who are depressed or anxious.Information card: At the time exit, patients file are checked for their vulnerability assessment especially if they have screened positive for depression and/or anxiety so that they could be referred to a nearest mental health facility for further assessment and care.7Inyour opinion, how this psycho-education for patients be improved Staff level: more support from MHFA/heads, division of workload, -Patient and companion level: should be informed about its importance that why it is needed outcome Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities inSindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216Now I would like to know your opinion psychosocial process for your colleagues/staff that has been implemented in your facility Information card: Psychosocial support process for maternity staff was also developed and implemented in your facility whose purpose was to reduce their work related stress and prevent them from burnout.8 psychosocial support for colleagues Barriers and facilitators in implementation of psychosocial support for staff Improvement of psychosocial support process for staff 1.0: Has the psychosocial support for staff been implemented here (if yes, how and [check all steps] if not they why not please give reasons) 1.1: Did you find any change in your behaviour or behaviour of your colleagues after getting training on psychosocial support for staff?Probes; -Staff level: more conscious about stress and its impact, increased knowledge, increased skill, better communication among each other, better team work, frequent use of support strategies -System level: more support from heads/MHFA Did you find any difficulties in implementation of psychosocial support process for staff?(specify, assessment, support (breathing, problem solving strategy, strengthening social support via connecting with people at work, home and other social set-up and referral) Supplement to: Avan BI, Hameed W, Khan B, Asim M, Saleem S, Siddiqi S. Understanding the mechanisms of change for a supportive and respectful maternity care intervention in public health facilities in Sindh, Pakistan.Glob Health Sci Pract.2023;11(6):e2300216. https://doi.org/10.9745/GHSP-D-23-00216 -Staff level: systematic and easy to guide, being used already, support/supervision from MHFA/SDMC officer to continue implementation -Patient level: Reduces patients distress, patients have sense of control, -Companion level: systematic guidance such as sharing its purpose gives meaning and encouragement to the patient and companion.-Stafflevel:share staff's burden in support provision, specific roles of companion make it easy to communicate, support/supervision from MHFA/SDMC -Staff level: enhances trust between patient and providers, support/supervision from MHFA/SDMC officer to continue implementation, contribution in promoting mental health -Patient level: patient get proper assessment and care, reflect that staff is concerned about their well-being -Companion level: engage in continuity of care and support Outcome 1.2: Did you find any difficulties in implementing the referral of patients with depression and/or anxiety, if yes probes:-Staff level: workload, not encouraged by the heads, lack of motivation, -Patient level: felt stigmatized, wanted staff to continue this support too -Companion level: lack of cooperation, not supporting referring of mental health specialists