Integrating community outreach into a quality improvement project to promote maternal and child health in Ghana.

Quality improvement (QI) is used to promote and strengthen maternal and child health services in middle- and low-income countries. Very little research has examined community-level factors beyond the confines of health facilities that create demand for health services and influence health outcomes. We examined the role of community outreach in the context of Project Fives Alive!, a QI project aimed at improving maternal and under-5 outcomes in Ghana. Qualitative case studies of QI teams across six regions of Ghana were conducted. We analysed the data using narrative and thematic techniques. QI team members used two distinct outreach approaches: community-level outreach, including health promotion and education efforts through group activities and mass media communication; and direct outreach, including one-on-one interpersonal activities between health workers, pregnant women and mothers of children under-5. Specific barriers to community outreach included structural, cultural, and QI team-level factors. QI efforts in both rural and urban settings should consider including context-specific community outreach activities to develop ties with communities and address barriers to health services. Sustaining community outreach as part of QI efforts will require improving infrastructure, strengthening QI teams, and ongoing collaboration with community members.