Better Health Outcomes through Mentoring and Assessment (BHOMA)
The BHOMA study is a cluster randomized community trial that aims to improve clinical care quality. The study has a stepped wedge design where the intervention was rolled out gradually until all the 40 health facilities received the intervention. The intervention aims to improve primary health care delivery. The primary outcome for the study is Age Standardized Mortality among persons under the age 60 years.
BHOMA is part of the Africa Health Initiative launched by the Doris Duke Charitable Foundation (DDCF), to strengthen the health systems so as to deliver integrated primary care to under-served populations. The BHOMA study commenced in 2009 and is funded by DDCF. Most of the area covered by the BHOMA intervention is classified as rural. Across Zambia, rural districts report consistently poorer health indicators than urban districts. The 2007 Zambia Demographic and Health Survey (DHS) indicates the level of disparity between urban and rural areas. BHOMA, therefore, has focussed on the districts with poor indicators of health with the aim of improving primary health care.
The study aims to improve primary health care through an integrated package of interventions, at both health facility and community level, centred on improving the patient-provider interface which is considered to be key to improving health outcomes. This intervention package is being carried out by the Center for Infectious Diseases and Research in Zambia (CIDRZ) while the evaluation of the impact of the intervention at population level will be conducted by Zambart, London School of Hygiene and Tropical Medicine (LSHTM). The primary objective of the evaluation is to measure the impact of the BHOMA intervention on health in the 3 districts through the measurement of carefully selected endpoints including Standardised Mortality Rate in the population less than 60 years, Under-five Mortality,Co-coverage score for under 5, Co-coverage score for adult health and Population level controlled HIV disease as a marker of a joined up health system. Main evaluation activities are:
- Community surveys
- Health facility surveys
- Qualitative studies
- Verbal autopsy activities and
- Economic Evaluation
Community surveys are being conducted in all catchment areas of the 42 health facilities at three points in time i.e. at baseline, midpoint and endpoint. The households are asked questions about their household composition and about deaths in the households. They are also asked about household amenities, health status of household members and will be offered various tests/checks including HIV, blood pressure, sugar level, height and weight. The baseline and midpoint studies have been conducted while the endpoint is planned to commence in July/August 2014.
Health facility surveys will be conducted annually in all facilities for three years. Data capture follows the World Health Organisation (WHO) health building blocks on health system strengthening including governance, finance, human resources, health information, Medical supplies and service delivery. The baseline and midpoint studies have been undertaken. The last one is also planned to commence in July/August, 2014.
The qualitative studies are being done through a Broad Brush Survey (BBS) in selected communities by a social science research team. The BBS aimed to compare key features of communities that could influence the uptake of interventions, level of community involvement and to document how communities experience and manage serious illness and death. The methodology included a mix of participatory methods (community mapping, transect walk, structured observations of places of interest and at night, timeline, free-listing, ranking, concept mapping, field diaries and FGDS with health committees, local leaders, different age and sex groups and pregnant women). Both the pre and post intervention evaluation studies have been undertaken.
The Verbal Autopsy (VA) entails the collection of detailed mortality data pertaining to the probable cause of death. Deaths recorded in the community surveys are followed up and this information is collected. The baseline VA has been undertaken. Economic Evaluation aims to assess health financing strategies and track the finances in the three districts in which interventions are being implemented for a period between 2010 and 2013. The study takes the project and health system’s perspective. Data will be collected through self-administered questionnaire, expenditure review and interviews with relevant personnel. The baseline assessment has been undertaken.
BHOMA has recorded a number of achievements and these include:
- The completion of two community surveys
- The completion of two health facility surveys
- The completion of one verbal autopsy survey
- The completion of pre and post intervention qualitative surveys
- Submission of two abstracts and posters to the 7th
- The National Health Research Conference in 2013 and National Science and Technology Exhibition in November,2013.Dissemination of specific site level qualitative baseline findings to all the 8 sites.
Margaret Tembo-Mwanamwenge, MPH is the Better Health Outcomes through Mentoring and Assessment (BHOMA) Study Evaluation Manager. She joined Zambart in 2010 after having worked as Census Manager and Principal Demographer for the Central Statistical Office.
She is currently pursuing a PhD programme with the London School of Hygiene and Tropical Medicine. She hopes her passion to see the attainment of improved health in her lifetime in Zambia will be realised within the confines of BHOMA.