Individual and organisational interactions, learning and information sharing in a multi-country implementation-focused quality of care network for maternal, newborn and child health: a social network analysis

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 302 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by the Medical Research Council (MRC) Health Systems Research Initiative 5th call via grant MR/S013466/1 to TC at UCL Institute for Global Health, United Kingdom, YS and JS at Johns Hopkins University, United States of America, KA and AK at Diabetic Association of Bangladesh Perinatal Care Project, Bangladesh, CM at Parent and Child Health Initiative, Malawi, GS at Makerere University School of Public Health, Uganda, and ME at University of Oxford, United Kingdom and by the Bill & Melinda Gates foundation via grant INV-007644 to TM at LSHTM, United Kingdom. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was obtained from University College London Research Ethics Committee (3433/003), BADAS Ethical Review Committee (ref: BADAS-ERC/EC/19/00274), Ethiopian Public Health Institute Institutional Review Board (ref: EPHI-IRB-240-2020), National Health Sciences Research Committee in Malawi (ref: 19/03/2264) and Makerere University Institutional Review Board (ref: Protocol 869). An information sheet detailing the survey was provided to all respondents the survey questionnaire was completed after obtaining written informed consent. All data is confidential and anonymised. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable All data is derived from a survey conducted with stakeholders who are in settings where only one individual holds a position at various levels and within institutions. Every care has been taken to ensure anonymity of the data in the submitted manuscript but the authors feel strongly that making data freely available would jeopardise the conditions of informed consent. We therefore request to be exempt from the requirement to make data available but have uploaded a detailed methods document. Thank you for your consideration.