Collaborative Improvement of Care and Support for Children and Families Affected by Zika in Selected Countries of Latin America and the Caribbean
As part of the USAID response to the Zika virus epidemic in Latin America and the Caribbean (LAC), the USAID ASSIST Project applied quality improvement (QI) and collaborative learning methods to strengthen prenatal care, newborn care, and care and support for children affected by the Zika virus during their mother’s pregnancy.
The USAID ASSIST Project’s Zika care improvement work was implemented in two phases, beginning in 2017. In the first phase, health facilities in the Dominican Republic, El Salvador, Guatemala, Honduras, and Nicaragua participated; in the second phase, activities in the original countries were expanded to new facilities and new Zika improvement programs were launched in Ecuador, Paraguay, and Peru as well as in five countries in the English-speaking Caribbean. This report describes the Zika care and support improvement work in the eight Spanish-speaking countries.
The Zika Care and Support Collaborative engaged 292 QI teams in the same number of health facilities in the eight assisted countries in the LAC region. These teams sought to improve case detection and care and support for newborns and children diagnosed with microcephaly or Congenital Syndrome associated with Zika virus (CSaZ), including providing psycho-emotional support for the families. The Care and Support Collaborative was the logical follow-on to the Newborn Care Collaborative to ensure that appropriate care was provided over time to those newborns identified with microcephaly or other anomalies associated with CSaZ.
The objectives of the Care and Support Collaborative were to: 1) Increase the identification and location of children with microcephaly or other manifestations of CSaZ (beyond those infants born in health facilities and including those who were born in facilities but later “lost to follow-up”; 2) link those cases to appropriate health facilities and referral facilities; and 3) provide complete and integrated care to all children affected by Zika infection and provide psychological and emotional support to their families.
To measure results and the effectiveness of improvement interventions, two indicators were tracked that were linked to these improvement objectives: 1) the percentage of children with microcephaly/CSaZ who were linked to care that received at least 80% of the clinical follow-up services by age in accordance with national norms; and 2) the percentage of mothers and caregivers who were attended by a provider trained in psycho-emotional support during each follow-up visit.
The results of the Care and Support Collaborative, show that in the beginning, countries made slow progress in the first indicator of percentage of children receiving 80% or more of the required services by age, per national guidelines, since teams were focused on identifying and locating cases and linking them to care but were challenged to produce evidence that the affected children received 80% of the stipulated services. The indicator reached 80% coverage in May of 2019 in the first phase countries. In the second phase countries, as the number of cases of microcephaly and CSaZ increased, there was a decline in the proportion who received 80% of required services, until coverage improved in 2019, reaching 80% by April 2019.
The second indicator of percentage of mothers attended by a provider trained in psycho-emotional support in each follow-up visit followed a similar pattern as the first indicator, but with higher levels of coverage: by March 2019, it reached 98% in the first phase countries and by June 209, 84% in the second phase countries.
The report describes the two main improvement strategies applied in all eight countries: 1) case managers, and 2) Extension for Community Healthcare Outcomes (ECHO) teleclinics. In addition, project teams in each country applied these traditional QI interventions to all parts of the continuum of care for Zika care and support: 1) norms and care protocols; 2) forms to document care; 3) training of health workers; and 4) job aids, equipment, and other inputs. The report also describes the best practices established by QI teams in eight countries:
- Active search for cases
- Locating children and families, working with local health committees, immunization field workers, traditional birth attendants, and community-based organizations
- Effectively linking cases to needed services, often coordinating with other institutions, cooperating agencies, and projects in order to ensure services for all cases, especially those located in remote communities
- Defining needed services by age
- Creating catalogs of available services
- Prioritizing care for Zika-affected children and families
- Enlisting private practitioners and grouping specialists so that families could receive multiple services on the same day
- Strengthening inter-institutional coordination
- Providing psycho-emotional support to families
- Expanding early infant stimulation and physical therapy services.
Finally, this report summarizes lessons learned in the implementation of the Care and Support Collaborative as well as recommendations for establishing integrated service networks, referral processes, and community-level services.