Author Affiliations:INDIGO¹, Centre for Global Health TCD1, 2, World Vision Ireland³, World Vision UK⁴

Option 2- Lessons from the field; project and programme evaluations; and syntheses or analyses Presented as – Oral Poster

Issues:

The availability of mobile phones in low-income countries has the potential to increase health service delivery; strengthen health information systems; improve data collection and monitoring; and provide support for health workers. There is a dearth of evidence demonstrating the impact of mobile phone applications on CHW motivation, supervision, attrition rates, as well as maternal and child health referral rates.

Description:

The Centre for Global Health is partnering with World Vision Ireland and UK to improve maternal, newborn and child health (MNCH) in Sierra Leone. 246 community health workers (CHWs) will be trained in the delivery of the 7-11 timed and targeted counselling strategy. 7-11 is an evidence-based framework that focuses on 7 key health interventions for pregnant women and 11 key health interventions for children under 2. These core interventions are promoted through a minimum of 10 timely visits by a CHW.

Methodology:

Each CHW will be associated to one of 26 health centre’s, whose health committee will be responsible for their direct supervision. Health centres will be matched according to their designation and catchment area to yield approximately 6 clusters, with 4 health centre’s included within each cluster. Health centre’s will subsequently be randomly assigned to one of three intervention groups: 7-11 training alone, 7-11 training combined with only a mobile phone, 7-11 training with a mobile phone equipped with an existing open-source application, which will be further developed as part of the study.

Next steps:

The impact of the mHealth application on CHW attrition rates will be assessed comparing levels of motivation, supervision, and activity across all three CHW intervention groups. The impact of the mHealth application on referral rates and follow up rates will be assessed by comparing the accuracy, completeness and timing of the monitoring information across the intervention groups.

Authors:Huq NL., Azmi AJ., Quaiyum MA., Hossain S.


Author Affiliations:International Centre for Diarrheal Disease Research, Bangladesh (ICDDR, B)

Option 1- Scientific / Empirical Research Findings Presented as – Oral Presentation (unable to present)

Aims:

Integration of innovative technology in health infrastructure would overcome the lack of universal access to maternal health services. A toll free mobile telephone intervention tested in one sub district of Bangladesh and prior to initiation and at project end qualitative assessments were conducted to understand the utility of mobile phone in increasing communication for maternal and neonatal complications.

Methods:

In-depth interviews were conducted among twelve CSBAs and fourteen mothers along with their husbands prior to intervention. At project end, six CSBAs were purposively selected for in-depth interview and a semi structured interview was conducted among all 27 CSBAs. One FGD was conducted with 10 recently delivered mothers. Thematic analysis and triangulation of responses from different respondents were conducted.

Results:

Prior to intervention, CSBAs reported that mobile communication was not a norm, also there was poor accessibility to mobile services mostly among poor women. Additionally, who communicated through mobile with providers noted irritability from provider’s side and sometimes found switched off of phone. At project end, 85% mothers who attended the orientation sessions communicated CSBAs through mobile phone for maternal health problems. Once a complication is reported or anticipated over phone communication, CSBA either made a prompt visit to mothers or direct referrals were advised. More than 80% CSBAs communicated with Solution Linked Group (SLG, SLG included specialized doctors), while in past SLG was not used to receive phone call from CSBA. At project end, CSBAs are making decisions on pregnancy-related matters in consultation with SLG over phone. CSBAs are valued, as mothers thought that CSBAs are becoming confident in managing complication due to communication with SLG.

Discussion/conclusions/ implications:

Active participation of service providers along with mothers’ accessibility is making mobile communication initiative successful. Direct and prompt referral reduced delay in management and enhance in receiving proper treatment rapidly.

Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, USA; Ifakara Health Institute, Mikocheni, Dar Es Salaam, Tanzania; University of Malawi, College of Medicine, Centre for Reproductive Health, Malawi; Centre for Global Health, University of Dublin, Trinity College; Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Mozambique

Option 1- Scientific / Empirical Research Findings Presented as – Oral Presentation

Aims:

The Health System Strengthening for Equity: The Power and Potential of Mid- Level Providers (HSSE) project sought to document the current use of nurses, nurse-midwives and NPCs in delivering EmOC in Malawi, Mozambique, and Tanzania.
One of the main aims of the project was to explore actual performance of EmOC and other related maternal and newborn health services by health workers who provided at least one of the EmOC signal functions in the previous three months preceding data collection in hospitals and health centres throughout Malawi, Mozambique, and Tanzania.

Methods:

A total of 2,065 health care providers from 286 facilities were surveyes in the three countries. Nurses, nurse-midwives, and NPCs comprised 75% of respondents (N=1,552).

Results:

EmOC signal functions are being performed by a wide range of skilled health care providers in the three study countries.


Over 75% of the nurses and nurse-midwives in the three study countries are providing four of the basic EmOC signal functions: administering parenteral antibiotics, uterotonics and anticonvulsants, as well as neonatal resuscitation.

Performance of all the comprehensive EmOC signal functions by NPCs was mixed.

Discussion/conclusions/ implications:

This study found that a range of skilled MLPs are providing life-saving EmOC signal functions in Malawi, Mozambique, and Tanzania, with nurses and nurse-midwives providing most of the basic EmOC signal functions and NPCs (and high level nurses in Mozambique) providing comprehensive EmOC. These MLPs and NPCs are providing care at different levels of the health care system, which often influences what EmOC services can and are provided to women in need. Given the paucity of doctors in these countries, our data reinforce the crucial role and use of MLPs as an innovative solution to addressing the human resource crisis in these countries.

Author Affiliations: 1Institute of Public Health, University of Heidelberg, Germany, 2 School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania

Option 1- Scientific / Empirical Research Findings

Presented as – Oral Presentation

Aims:

This study was conducted in the frame of the QUALMAT research project which seeks to improve the quality of Maternal and Neonatal health (MNH) care in rural sub-Saharan Africa. It was undertaken in Tanzania to gain a detailed insight into the influences on MNH provider motivation, performance and job satisfaction.

Methods:

35 in-depth interviews were conducted with primary level MNH providers and their managers. The interview guideline development was led by Tanzanian psychologists, sociologists and health professionals.

Results:

Key sources of encouragement include community appreciation, perceived government and development partner support for MNH, and on-the-job learning. Discouragements are overwhelmingly financial in nature, but also include facility understaffing and the resulting workload, malfunction of the promotion system as well as health and safety and security issues. Low level cadres are found to be particularly discouraged. Difficulties and weaknesses in the management of rural facilities are found. Basic steps that could improve performance appear to be overlooked. Motivation is generally referred to as being fair or low. The providers derive quite a strong degree of satisfaction, of an intrinsic nature, from their work.

Discussion/conclusions/ implications:

The influences on MNH provider motivation, performance and satisfaction are shown to be complex and to span different levels. Variations in the use of terms and concepts pertaining to motivation are revealed, and further clarification is needed. Intrinsic rewards play a role in continued provider willingness to exert an effort at work. The critical nature of MNH and the rural setting readily expose a health workers performance. The causes of discouragement can be broadly divided into those requiring renewed policy attention and those which could be addressed by strengthening the skills of rural facility managers, enhancing the status of their role and increasing the support they receive from higher levels of the health system.

Author Affiliations:1 Institute of Public Health, University of Heidelberg, Germany, 2 Navrongo Health Research Centre, Ghana, 3 Independent Public Health Consultant, Switzerland, 4 School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Tanzania, 5 Institute of Psychology, University of Heidelberg, Germany

Option 1- Scientific / Empirical Research Findings Presented as - Poster

Aims:

The QUALMAT project seeks to improve the quality of maternal and neonatal health (MNH) care in rural sub- Saharan Africa. Provider skills and motivation levels are considered to hold the key to their performance. An incentive scheme and a Clinical Decision Support System will be piloted at selected primary level facilities. Here the development of an instrument to monitor the effects of these interventions on MNH provider motivation in Ghana is described.

Methods:

The process was informed by a literature review, the QUALMAT conceptual framework and qualitative research conducted in Ghana. A panel approach was used to identify constructs where changes were expected. These pertained to the working context (performance and management aspects), as well as to the providers attitudes and behaviour (individual aspects). Items were elaborated for each construct, referring, wherever possible, to tools that had already been used in the context of developing countries. The items pertaining to provider behaviour (timeliness, attendance etc) were also included in a further, short instrument for completion by a peer. For both instruments a 4-point likert scale was used.

Results:

The self-administered and peer administered instruments were pre-tested with 75 health workers in Ghana in July 2011. Subsequently, 23 items with poor psychometric performance were eliminated. Factor analysis of the remaining 42 items confirmed the use of the three aspects which accounted for 56% of the variance. Cronbach’s alpha was 0.871.

Discussion/conclusions/ implications:

The items that performed poorly came from the constructs ‘self-efficacy’, ‘work meaningfulness’ and ‘motivation’ itself, indicating the need for further research into these concepts in the context of Ghana. This is partly endorsed by findings from the qualitative research. Negatively phrased questions worked less well, indicating that they were not so readily understood. The responses made by peers were overwhelmingly positive, implying possible cultural limitations to this approach.