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Table 4 Heshima process description (including interventions)

From: Sowing the seeds of transformative practice to actualize women’s rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research

  Intervention Activity Purpose Participants Frequency Duration Location
Policy level
 1. Project Launch High level MOH officials launched Heshima. Media invited. Participants invited to Project Steering Committee to guide/monitor activities. 80 One time One morning Nairobi
 2. Project Steering Committee Maternal health champions known to Heshima with mandate to support quality childbirth met routinely to review project progress See Table 4 12 Half day Nairobi
 3. Global Policy Review Desk review of international conventions, treaties, signed by Kenya, national laws, and the new constitution for relevant policies and guidelines on human and childbearing rights for promoting and strategizing for RMC by The Council and FIDA. FIDA lead One time 20 days Nairobi
 4. Baseline questionnaire development training of data collectors Formative research conducted to understand the context and mistreatment terminology by communities and provider motivation and accountability issues prior baseline questionnaire development.
Health managers from national nursing and reproductive health units were invited to be part of the data collector training. Specifically requested to coordinate observations of client provider interactions during labor and delivery in the 13 study facilities.
Heshima and steering committee
Heshima (Council led), MOH, data collectors
Ad hoc meetings 30 days Nairobi & non- study site
One time 1 week Nairobi
 5. Community Dialogue and National Stakeholder Forum Community level findings disseminated in each facility catchment area
Stakeholders: community, facility, national, global representatives. Baseline findings – drivers of disrespect and abuse (See Fig. 2) – disseminated then group work by level and county to suggest interventions to mitigate disrespect and abuse.
1996 community members 100 stakeholders One time 1 day Nairobi
 6. Participatory Intervention Development Meetings with Heshima members and Steering Committee to review discussions from No.5. 20 Series of meetings 1 month Nairobi
 7. Development of RMC Resources and Curricula 1) Baseline results and stakeholder consensus on the content of training materials; 2) Values components adapted from IPAS training materials; 3) Sessions on rights based approach, service charter including accountability. 4) Added professional code of ethics. 5) MOH convened national meetings on RMC curricula development for both pre- and in-service training; 6) Final face to face meeting with project partners and steering committee members refined the RMC resource package; and 7) Two international experts reviewed final version prior to completion. RMC components were incorporated into national curriculum. 10–15 national maternal health stakeholders 7 members Nursing Council of Kenya 3 meetings plus virtual experts in training material development 7 days
30 days
 8. National Policy Dialogue and Development Policy engagement through the national reproductive health interagency coordination committee, technical working groups for maternal and newborn health, Human Resource and monitoring and evaluation. Presentations of results to get buy in prior to national dissemination. Meetings continued for scale up plans. 20–40 stakeholders /meeting 4–8 meetings (quarterly) half day Nairobi
The Council participated in small expert meetings (invitees only) to draft Maternal Health Bill and ensure disrespect and abuse during facility based childbirth incorporated. 10–15 national stakeholders 15 meetings Half day /meetings Nairobi
Working with the high level policy makers such as Kenya Women’s Parliamentary Association, the Parliamentary Health Committee and the first Lady to advocate for Reproductive /Maternal Health Rights. Over 50 3 strategic meetings Plus ongoing Half day meetings Nairobi
 9. Advocacy National conferences and meetings with media (e. g. Kenya Media Network), researchers, professional associations (midwifery, ObGyn and medical) and policy makers on health rights and promoting RMC. Continuous advocacy by MOH and Heshima. 120 national stakeholders 12 targeted meetings. Half day national meetings Nairobi / county level
Health system - Facility level
 10. VCAT Workshops RMC workshop (1–2 days) for county health managers, facility and maternity in charges, i.e. those who supervise /support frontline providers
Three day workshop for facility staff. Each of the study facilities developed action plans to institutionalize RMC in maternity units.
Maternity providers
One time /county
Facility reps to one meeting
2 -day workshop 3- days /workshop All study Counties and facilities
 11. Mentorship Following VCAT workshops, on-the-job role-modeling for provider behavior change by facility champions as part of routine continuous professional development. 13 identified, 4 actively engaged Conducted as part of routine work continuous on job session 4 sites: 2 public, 2 private
 12. Quality Improvements teams Strengthened facility management and quality improvement teams to monitor, address, and resolve incidents of mistreatment. Address infrastructure, drugs and commodity supply concerns. Quality improvement teams trained on rights and obligations related to childbirth, developed protocol for reporting and monitoring, and encouraged community membership.
Established mechanisms for transparency and accountability of health facilities to communities, increase awareness of maternal healthcare rights.
Public facilities −10; private facilities −0) 3–6 members Quarterly review meetings 4 x year Ongoing and 2–3 h meeting All study counties
 13 Counseling for providers Counseling for providers at the group and/or individual levels to support providers with coping mechanisms to overcome experiences related to high workload, trauma or critical incidents. Conducted by FIDA counselors (one counseling session per site) and role modelled sessions with the facility or county counsellors. Counselors continued with counseling sessions in their respective sites. 113 providers (8–12/ site) 26 sessions; 9 sites one each. 4 sites; 3–4. 45 min- 1 h per session All study counties
 14 Maternity Open Days Trust-building with local communities: men and women visit the facility to learn about procedures in the maternity wards and interact with staff. 100–300 depends on facility size 24 (total) 1 day each All study counties
 15 Monitoring of disrespect and abuse Provided mechanisms to report incidents of disrespect and abuse such as customer service desks, suggestion boxes and through Heshima/MOH supervision. County health teams and facility quality improvement teams conducted monitoring and supervision as part of their routine work. ~350 community members
~35 at facilities
17 county visits 22 community health units; 13 facility visits** ½ day community health units and ½ day facility All study counties
Community level
 16 Community workshops One day workshop held for community resource persons (community health volunteers, legal aids, chiefs, religious leaders/village elders) on civic education of community rights to sexual and reproductive health including maternal health care. FIDA facilitated the workshop. CHEWs support community health volunteers to develop action plans. 154 community people trained 5 times (1 per county) 1 day each workshop Catchment of all facilities
 17. Community education and male involvement Community health volunteers, CHEWs, opinion leaders, civil and legal aids) conducted RMC sensitization meetings for community members with support from county mangers.
Deliberate efforts were made to involve men in the community workshops as participants and facilitators. Targeted meetings for men: ‘calling them to action’ to demand RMC for their wives and partners.
1996 people: 287 male only, 871 female only, 838 mixed groups 27 meetings Half day Catchment areas from around facilities
 18. Mediation training for society leaders Trained society leaders (e. g. CHVs), on mediation skills, to act as intermediaries between community members and health facility to address issues of disrespect and abuse. Mediators selected by communities and facilities (on set criteria) and trained by FIDA. ***
Counseling community members who have experienced mistreatment. Led by FIDA and other professional counselors. Referrals from CHVs or community legal aids.
22 from community health units, 13 from facilities 2 out of 6 women 5 times (1 per county)
1 day per session
1 h per session
All study counties
One site
  1. *FIDA uses routine lobbying processes on civic and women’s health issues to advocate of behalf of Heshima. **In some counties, community units shared between multiple facilities. *** In RMC Resource Package Manual