Travel scenario workshops for geographical accessibility modeling of health services: A transdisciplinary evaluation study

Abstract

Introduction: Limited geographical access to quality Emergency Obstetric and Newborn Care (EmONC) is a major driver of high maternal mortality. Geographic access to EmONC facilities is identified by the global community as a critical issue for reducing maternal mortality and is proposed as a global indicator by the Ending Preventable Maternal Mortality (EPMM) initiative. Geographic accessibility models can provide insight into the population that lacks adequate access and on the optimal distribution of facilities and resources. Travel scenarios (i.e., modes and speed of transport) used to compute geographical access to healthcare are a key input to these models and should approximate reality as much as possible. This study explores strategies to optimize and harmonize knowledge elicitation practices for developing travel scenarios.

Methods: Knowledge elicitation practices for travel scenario workshops (TSW) were studied in 14 African and South-Asian countries where the United Nations Population Fund supported ministries of health and governments in strengthening networks of EmONC facilities. This was done through a mixed methods evaluation study following a transdisciplinary approach, applying the four phases of the Interactive Learning and Action methodology: exploration, in-depth, integration, and prioritization and action planning. Data was collected in November 2020-June 2021 and involved scoping activities, stakeholder identification, semi-structured interviews (N = 9), an evaluation survey (N = 31), and two co-creating focus group discussions (N = 8).

Results: Estimating realistic travel speeds and limited time for the workshop were considered as the largest barriers. The identified opportunities were inclusively prioritized, whereby preparation; a favorable composition of attendees; validation practices; and evaluation were anticipated to be the most promising improvement strategies, explaining their central place on the co-developed initial standard operating procedure (SOP) for future TSWs. Mostly extensive preparation-both on the side of the organization and the attendees-was anticipated to address nearly all of the identified TSW challenges.

Conclusion: This study showed that the different identified stakeholders had contradicting, complementing and overlapping ideas about strategies to optimize and harmonize TSWs. Yet, an initial SOP was inclusively developed, emphasizing practices for before, during and after each TSW. This SOP is not only relevant in the context of the UNFPA EmONC development approach, but also for monitoring the newly launched EPMM indicator and even in the broader field of geographic accessibility modeling.

Keywords: emergency obstetric care; geographic accessibility; interactive learning; maternal health; travel scenario.

Figure 1

Learning action spirals of the transdisciplinary approach. Each individual curve indicates the separate phases of the approach. The research activities undertaken are shown around the curves. The spirals point to the feedback loops between the different research activities and show how all activities are interconnected and benefit from each other.

Figure 2

Map showing where the UNFPA EmONC program was implemented by 2021, while indicating where survey (quantitative) and in-depth interview and FGD (qualitative) participants attended the TSWs. The blue color gradient indicates the number of survey responses. Dashed countries indicate countries where the in-depth interview and FGD participants attended TSWs. The combined exploratory- and in-depth interview participants together covered for TSW attendance in all 14 indicated countries.

Figure 3

Power-knowledge grid of identified stakeholder groups. The stakeholder division over the power axis is based on the TSW organization within the UNFPA EmONC development approach and further explained/substantiated by the arrows within the figure. The level of relevant knowledge attributed to each stakeholder group is based on the survey results (Supplementary Table 2).

Figure 4

Sankey diagrams showing which challenges were most frequently emphasized by the interview participants.

Figure 5

Sankey diagrams showing which opportunities were most frequently emphasized by the interview participants.

Figure 6

Weighted average-ranking of most promising strategies to optimize travel speed estimations by survey and focus group discussions. Colors indicate separate strategies. Lines indicate the changes in ranking position respective of the survey and focus group discussions.

Figure 7

Facilitation-feasibility grid for the prioritization of identified opportunities. The left grid shows the results for focus group 1 while the right grid shows the results of focus group 2. Each identified opportunity is ranked according to the mutually agreed level of facilitation and feasibility.