Driving Change in Maternal Anaemia Management: A Contextual Evaluation of a Quality Improvement Initiative for Routine Screening and Intravenous Iron Treatment in Nigeria

Abstract Background: Quality improvement (QI) models have been applied in healthcare systems with varying success, raising questions about their effectiveness. Despite growing evidence on effective interventions, a gap remains between proven strategies and actual practice, particularly in low- and middle-income countries (LMICs). Evaluating the efficacy of QI initiatives and understanding the contextual factors influencing their success is crucial. This study aims to investigate the roles and interrelationships of contextual factors in implementing the Diagnose-Intervene-Verify-Adjust (DIVA) approach for the Implementation Research for Intravenous Iron Use in Pregnant and postpartum Nigerian Women (IVON-IS) project, which seeks to enhance anaemia screening and treatment using intravenous ferric carboxymaltose (FCM). Methods: We used a mixed method approach with a sequential explanatory design. Adapting the Model for Understanding Success in Quality (MUSIQ), we quantitatively compared contextual factors affecting DIVA implementation across six health facilities participating in the IVON-IS project. Multi-stakeholder Implementation Management Team (IMT) members from the health facilities implementing the IVON-IS project completed a self-administered questionnaire. Qualitative interviews were conducted via in-depth interviews with 12 IMT members using an open-ended semi-structured interview guide. Quantitative data was analysed descriptively, and qualitative interviews were analysed using a framework analysis approach. Results: The IVON-IS implementing facilities scored between (87.6%) and (95.4%) out of 168 points on the MUSIQ scale, suggesting a reasonable likelihood of project success. All facilities demonstrated strong performance across MUSIQ domains, including external environment, QI team attributes, organizational capacity, microsystem, and QI support and capacity on the MUSIQ scale. Notably, external motivators scored lowest. Supportive leadership, strong microsystems and diversity of the QI team are contextual factors that facilitated the project. However, barriers such as the regulatory and policy environment and QI workforce were identified. Conclusion: Based on the MUSIQ assessment, the IVON-IS project exhibited a reasonable chance of success. Our study highlights the utility of MUSIQ in designing and implementing sustainable QI initiatives. The framework's structured approach facilitated identifying and managing key drivers of quality care, resulting in lasting improvements in healthcare processes.