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Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania
Accepted Manuscript Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania Miyuki Oka, Shigeko Horiuchi, Yoko Shimpuku, Frida Madeni, Sebalda Leshabari PII: DOI: Reference:
S2214-1391(17)30098-7 https://doi.org/10.1016/j.ijans.2018.11.005 IJANS 123
To appear in:
International Journal of Africa Nursing Sciences
Received Date: Revised Date: Accepted Date:
5 November 2017 14 November 2018 22 November 2018
Please cite this article as: M. Oka, S. Horiuchi, Y. Shimpuku, F. Madeni, S. Leshabari, Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania, International Journal of Africa Nursing Sciences (2018), doi: https://doi.org/10.1016/j.ijans.2018.11.005
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Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania Miyuki Oka, NM, MSN1) §, Shigeko Horiuchi, NM, PhD1) *, Yoko Shimpuku, NM, PhD1) *, Frida Madeni, NM, MSN2) *, Sebalda Leshabari, NM, PhD3) *
1)
St. Luke’s International University, Tokyo, Japan
2)
Korogwe District Hospital, Tanzania
3)
Muhimbili University of Health and Allied Sciences, Tanzania
*These authors contributed equally to this work
E-mail addresses: Miyuki Oka: [email protected] Shigeko Horiuchi: [email protected] Yoko Shimpuku: [email protected] Frida Madeni: [email protected] Sebalda Leshabari: [email protected]
§Correspondence:
Miyuki Oka
Graduate School of Nursing Science St. Luke’s International University 1
10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan E-mail: [email protected]
Authors’ information MO has 10 years of experience as a midwife and nurse in Japan. She has not only spent several months conducting research in Tanzania, but also served as a nurse tutor at a nursing and midwifery school in rural Tanzania.
SH is a professor and YS is an assistant professor of St. Luke’s International University specializing in midwifery. They have a long experience as researchers in the fields of nursing and midwifery.
FM is a midwife and district nurse officer at Korogwe District Hospital in rural Tanzania. She also has much experience as a researcher and midwife in clinical practice.
SL is the Dean of the School of Nursing in Muhimbili Health and Alliance University. She is a one of the leaders and authorities of midwifery education in Tanzania and has many years of experience as a midwife and a researcher. 2
All the authors are members of the Asia Africa Midwifery Research Center (AMReC) of St. Luke’s International University, Japan.
Authors’ contributions MO designed this study, conducted the educational program, acquired and analyzed data, and primarily wrote the manuscript. YS and FM supported the conduct the educational program. MO drafted the manuscript and SH, YS, FM, and SL made critical reviews and important revisions.
Acknowledgements The authors thank all the study participants, namely, the director, nurse administrators, nursemidwives, and antenatal care attendees in the hospital at Muheza in Tanzania. The authors also thank Dr. Edward Barroga for guidance in writing and revising the paper.
Abstract Background: In developing countries, nurses’ counseling during antenatal care (ANC) visits remains insufficient. We examined the effects of a job aid-supported intervention 3
on understanding the danger signs and improving the caring behaviors of nurses to women in rural Tanzania. Methods: This was a hospital-based research using a quasi-experimental pre-post study design. All nurses engaged in ANC counseling participated in a three-hour training covering counseling skills, pregnancy danger signs, use of a job aid, and quality of caring behaviors. The sample consisted of women who attended the ANC clinic and had no intrauterine fetal death. The primary outcome was perception of receiving information on the danger signs by women. The secondary outcome was impressions of women regarding the caring behaviors of nurses. Women answered questionnaires following ANC counseling (baseline) and two weeks postintervention (endline). Results: Of 318 women, 148 participated at baseline and 170 at endline. Regarding receiving information on danger signs, the mean baseline score of 4.92 (SD = 2.99) and the mean endline score of 6.66 (SD = 2.38) were significantly different (t = 5.646, p < .01). Regarding impressions of the nurses’ caring behavior, the mean total baseline score of 26.17 (range, 6-30; SD = 11.19) and the mean total endline score of 27.63 (SD = 6.81) were significantly different (t = 4.299, p < .01). Conclusion: The job aid-supported intervention during ANC counseling found differences in the responses to receiving information on the danger signs of pregnancy and in identifying the caring behaviors of nurses to women. 4
Keywords: Pre-post study design, Pregnancy, Teaching materials, Antenatal care, Health knowledge, Attitude, Practice, Tanzania
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Background The third goal in the United Nations Sustainable Development Goals (SDGs) is to ensure healthy lives and promote the well-being of everyone at all age groups. This goal focuses on improving equity to meet the needs of women, children, and the poorest most disadvantaged people especially in developing countries (World Health Organization [WHO], 2015a). One of these countries is Tanzania which has a very high maternal death rate of 556 per 100,000 births (Ministry of Health, Community Development, Gender, Elderly and Children [MoHCDGEC], Ministry of Health [MoH], National Bureau of Statistics [NBS], Office of the Chief Government Statistician [OCGS], and ICF, 2016). Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries. Such delay has three aspects: delay in deciding to seek care, delay in reaching care, and delay in receiving skilled care (Thaddeus & Maine, 1994). These aspects commonly occur and become predictable by observing various situations surrounding pregnant women. Thus, women, their families, communities, health providers, and facilities may be able to prevent such delays by being carefully prepared. WHO states that birth preparedness and complication readiness (BP/CR) is an essential strategy in the provision of antenatal care (ANC) (WHO, 2015b). BP/CR is the process of planning for a safe birth and takes into consideration the desired 6
place for giving birth, the preferred birth attendant, and funds for any expenses related to birth and in case of complications. Interventions based on the BP/CR concept have been instituted to achieve reductions in maternal and neonatal deaths (JHPIEGO, 2004a; Lassi, Haider, & Bhutta, 2010; Prost et al. 2013; Soubeiga, Gauvin, Hatem, & Johri, 2014). In particular, systematic reviews of BP/CR interventions in populations of pregnant women living in developing counties have been conducted and BP/CR at the community level have been implemented (Lassi, Haider, & Bhutta, 2010; Prost et al. 2013; Soubeiga, Gauvin, Hatem, & Johri, 2014). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women, their families, and the community (Kearns, Hurst, Caglia, & Langer, 2014). The information or counseling provided may include various areas such as signs of complications and labor, emergency preparedness, preventive home practices, and support for seeking emergency facilities (WHO, 2006). Unfortunately, counseling practices during ANC visits remain poor and inefficient, particularly in Burkina Faso, Ghana, and Tanzania (Duysburgh et al., 2013) and in rural Tanzania (Pembe et al., 2010). In fact, Duysburgh et al. (2013) found that 39.5% of Tanzanian pregnant women were not informed of any danger signs of pregnancy, and that 30.0% of them could not state any danger signs of pregnancy following ANC counseling (Duysburgh et al., 2013). Pembe et al. (2010) suggested that 7
the poor performance of nurses in rural Tanzania could be due to the limited human resources, short ANC time, poor knowledge of the importance of counseling on BP/CR, and low motivation. Others have indicated that the poor outcome of counseling on pregnancy is also attributable to the poor awareness of the danger signs of pregnancy among women who have attended ANC (Mutiso, Qureshi, & Kinuthia, 2008). Moreover, in the description of women’s perception about maternity services in rural Tanzania, Miltenburg et al. (2016) found that pregnant women were occasionally afraid of the response of healthcare workers as this might come in the form of a scolding. This finding might have affected the women’s poor awareness of health information regarding pregnancy. A recent survey in Tanzania has shown that 98% of pregnant women visit ANC at least once, and only 51% visit ANC four times or more (MoHCDGEC, MoH, NBS, OCGS, and ICF, 2016). Notably, only 13% of facilities offering ANC had visual or job aids for educating women (NBS, 2007). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010). Job aids have been shown to be effective in 8
improving the performance of nurses (Knebel, 2000; Leshabari, Koniz-Booher, Burkhalter, Hoffman, & Jennings, 2007; Jennings, Yebadokpo, Affo, & Agbogbe, 2010). For instance, job aids have provided important information on infant feeding or how to perform malaria rapid diagnostic tests (Leshabari, Koniz-Booher, Burkhalter, Hoffman, & Jennings, 2007; Harvey, Jennings, Chinyama, Masaninga, & Mulholland, 2008). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care (Jennings, Yebadokpo, Affo, & Agbogbe, 2010). This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses. This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.
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Methods
Study design This research used a quasi-experimental pre-post study design.
Setting After obtaining permission, this study was conducted in a hospital at Muheza district in the Tanga region of Tanzania. Muheza district is one of the eight districts in the Tanga region located in the northeastern part of Tanzania, and approximately 25 km from Tanga city. Muheza is served by 54 dispensaries, four health centers, and one district hospital (Kahabuka, Kvåle, Moland, & Hinderaker, 2011). In the setting hospital, there were 4,513 deliveries, 723 cesarean sections, 11 maternal deaths, and 67 neonatal deaths in 2014 (Rajabu, 2015).
Sample selection The study population consisted of all pregnant women who attended the ANC clinic during the study period and who understood Kiswahili as inclusion criteria. The exclusion criterion was pregnant women who had a diagnosis of intrauterine fetal death.
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Sample size The minimum sample size providing usable data for analysis should be five times the number of variables (Streiner, 1994). The dropout rate was estimated as 30%, thus the approximate sample size needed was at least 124.
Study period This study was conducted from the end of June 2015 to the early part of August 2015.
Description of job aid-supported intervention The job aid-supported intervention training was conducted on July 4, 2015. All nurses (n = 29) who provide ANC counseling at the setting hospital participated in the training for three hours. The contents of each program goal are shown in Box 1. For this study, the first author (MO) developed the contents of the three-hour training on the basis of a simulation-based training (Nelissen et al., 2015), educational material on monitoring BR and CR (JHPIEGO, 2004b), and a handbook for counseling on maternal and newborn health care (WHO, 2010). The training covered various areas, namely, counseling skills, and preparations for childbirth and danger signs of pregnancy, use of the booklet “Nne na Tano” as a job aid, and quality of caring behavior. The training was called “Let’s talk!” (Zungmunza Vizuri) and involved a discussion about birth preparedness between 11
nurses and pregnant women or pregnant women and their relatives with the aim of improving the quality of life of all concerned. The co-authors (YS and FM) of this study developed a short story booklet called ‘Nne na Tano’ (Shimpuku & Madeni, 2014) based on BP/CR concepts written in Kiswahili. The booklet measures 15 x 21 cm, has 22 pages, and is printed in full color pictures for each page. This booklet describes a story about BP/CR. Nne and Tano are the two main pregnant women characters in the short story. Nne prepares well for her birth whereas Tano does not. The first two pages explain the booklet and the last two pages show the danger signs of pregnancy using pictures and bullet points.
Please insert Box 1 here.
Outcome measures: instruments The study measured two outcomes. The primary outcome was the perception of receiving information on the danger signs of pregnancy by pregnant women. The secondary outcome was the impression of pregnant women on the caring behavior of nurses. The first author (MO) developed the questionnaires for pregnant women in accordance with the study purpose. The items of these questionnaires were developed based the WHO guide on pregnancy, childbirth, postpartum and newborn care (WHO, 12
2003). The items of danger signs of pregnancy included vaginal bleeding, severe headache with blurred vision, fits / convulsion, difficult breathing, fever, too weak to get out of bed, water break, and abdominal pain. The items of the impression of pregnant women on the caring behavior of nurses asked pregnant women their impressions of the nurses’ behavior which included the following: kind, arrogant, respectful, abusive, understanding, and cold.
Translation process The questionnaire was developed in English and then translated to Kiswahili by the local co-author who had experience as a local midwife. Back translation to English was carried out by another experienced co-author to identify not only linguistic equivalence but also the conceptual and cultural equivalence (WHO, 2018; Maneesriwongul & Dixon, 2004).
Primary outcome: perception of receiving information on the danger signs of pregnancy by pregnant women A test was developed to estimate the perception of receiving information on the danger signs of pregnancy. The test consisted of eight items derived from the WHO guide on pregnancy, childbirth, postpartum and newborn care (WHO, 2003), and previous studies 13
(Pembe, 2009; Urassa, Pembe, & Mganga, 2012). These questions asked the pregnant women if they were provided proper information on the danger signs of pregnancy at their ANC visit: 0) no or 1) yes. The scores ranged from zero to eight points. A high score indicates that the nurses provided proper information.
Secondary outcome: impression of pregnant women on the caring behavior of nurses The questions for the secondary outcome consisted of six items developed on the basis of the counseling skills described in the handbook on Counseling for Maternal and Newborn Health Care (WHO, 2010). The six items gauged the impression of the pregnant women on the caring behavior of nurses from 1) strongly disagree to 5) strongly agree. The score range is from six to 30 points, with higher scores indicating a perception of a more positive and caring behavior by the nurses. One question [answerable by 0) no or 1) yes] was specifically included to confirm if pregnant women were encouraged by a nurse to attend the next ANC service. A score of 1) means that the nurse mentioned the next ANC service to the pregnant women.
Content validation The instruments were assessed for content validity by three experienced midwife researchers. The researchers encountered no problems with the description of the 14
primary and secondary outcomes used in this study; minor corrections were made for some questions such as adding some statements that are more suitable for their situation, changing some phrases for better understanding, and technical editing. Substantive changes were not made to the instruments.
Data collection The first author and co-author (FM) selected the eligible pregnant women as respondents from all the pregnant women who visited the clinic for a regular antenatal check-up during the study period. Then, they explained the study to the eligible pregnant women immediately after undergoing the ANC counseling. If the pregnant women gave their consent to participate, the first author and co-author (FM) immediately asked each woman the questions from the author-developed questionnaire and wrote down the pregnant women’s responses at that time. The questionnaires for the pregnant women were collected immediately after the ANC counseling (baseline) and two weeks after the job aid-supported intervention (endline). The data collection process at the endline was managed similarly to the data collection process at the baseline. Specifically, after the job aid-supported intervention, the questionnaires were managed similarly and also consisted of the same 19 items.
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Data analysis Analysis of variance was used to compare the effects of the job aid-supported intervention using the average scores at baseline (after the ANC counseling) and endline (two weeks postintervention). Differences were analyzed by the unpaired t-test and chisquare test using SPSS version 22.0 for Windows.
Ethical consideration The study was conducted based on the principles of ethics such as harmlessness, voluntarily participation, anonymity, and protection of privacy and personal information. Participation in the study was voluntary and written informed consent was obtained from all pregnant women. The participants received an explanation regarding their right to refuse or withdraw their consent, or to stop participating using the refusal form. Ethical approval of this study was obtained from the Tanzania National Institute for Medical Research (NIMR) (Ref. NIMR/HQ/R.8c/Vol. IX/1604) and the Tanzania Commission for Science and Technology (COSTECH) (No. 2015-127-EF-2013-101). Ethical permission was also obtained from the Ethics Committee of St. Luke’s International University, Japan (Approval number: 15 - 007).
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Results
All data from the pregnant women were collected immediately after they received ANC counseling (baseline; June 29, 2015 – July 3, 2015) and two weeks after the intervention (endline; July 21-31, 2015).
Demographic characteristics of pregnant women (Table 1) The total number of respondents in this study was 318 pregnant women. Of these 318 pregnant women, 148 participated at baseline and 170 participated at endline. The demographic characteristics of the pregnant women at baseline and endline are shown in Table 1. The ages ranged from 16 to 50 years at baseline, and from 18 to 45 years at endline. More than 50% of the participants were in their 20s and the participants in the next older group were in their 30s. Both groups had less than 10% of participants in their 40s. The highest educational level attained by most of the pregnant women was Primary school in both groups. This was followed by Ordinary secondary school, No education or Incomplete primary school, and Advanced secondary school or above. Over half of the pregnant women were multigravida women in both groups compared with primigravida women.
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The highest number of times of choosing to visit the ANC clinic was two or three times in both groups. This was followed by one time, and then four times or more. There were no significant differences in the age, educational level, parity, and number of times of visiting the ANC clinic among the pregnant women between the two groups.
Please insert Table 1 here.
Perceptions of receiving information on danger signs of pregnancy by pregnant women (Table 2) The questionnaire consisted of eight-item questions. The questions asked whether the pregnant women received information on the danger signs of pregnancy from the nurses immediately after finishing the ANC counseling (baseline) and two weeks postintervention (endline) (Table 2). The mean scores of Information on danger signs provided by nurses were 4.92 [SD = 2.99] (baseline) and 6.66 [SD = 2.38] (endline), showing a significant difference (t = 5.646, p < .01). The chi-square test indicated that the percentages of pregnant women given information on all the individual danger signs were significantly different between the baseline and the endline (Table 2). The danger signs that had larger disparities between the two scores from the highest to the lowest were Fits / Convulsion (x2 = 22.630, p 18
< .01), Water breaking (x2 = 22.322, p < .01), Fever (x2 = 20.419, p < .01), and Too weak to get out of bed (x2 = 20.189, p < .01). In terms of the percentage of pregnant women who received (indicated in Table 2 as “Yes”) and who did not receive (“No”) information on danger signs, the danger signs Fits / Convulsion and Too weak to get out of bed showed a lower percentage for Yes at baseline than at endline. There was a large increase in the percentage of participants from baseline to endline reporting that they received (Yes) information on the danger signs Fits / Convulsion from 45.9% to 72.2% and Too weak to get out of bed from 52.4% to 76.5% (Table 2). Abdominal pain and Fever showed the highest percentage in pregnant women who received (Yes) such information both at baseline and at endline. Specifically, the percentage of pregnant women receiving information on Abdominal pain increased from 75.7% (baseline) to 90.6% (endline), and on Fever from 72.4% (baseline) to 91.7% (endline). Overall, the percentage of pregnant women receiving information on danger signs from nurses was higher at endline than at baseline.
Please insert Table 2 here.
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Impressions of pregnant women on the caring behavior of nurses (Table 3) A comparison of the mean scores of impressions of pregnant women on the caring behavior of nurses at baseline and endline is shown in Table 3. The total scores ranged from six to 30 with a mean of 26.17 (SD = 11.19) at baseline and 27.63 (SD = 6.81) at endline, showing a significant difference (t = 4.299, p < .01). The impressions consisted of ideal caring behaviors toward pregnant women at ANC counseling, namely, being Kind, Respectful, Reliable, Careful, Understanding, and Warm (Table 3). The scores of all the impressions were significantly different between the baseline and the endline as shown by the t-test. Being Reliable showed the highest t value (t = 4.278, p < .01), followed by being (in descending order) Respectful (t = 3.781, p < .01), Careful (t = 3.648, p < .01), Understanding (t = 2.997, p < .01), Kind (t = 2.730, p < .01), and Warm (t = 2.274, p < .01). Taken together, the pregnant women showed higher mean scores of impressions on the caring behaviors of nurses at endline than at baseline.
Please insert Table 3 here.
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Discussion
Pregnant women’s perspective on ANC counseling Pregnant women were asked whether they perceived receiving information on the danger signs of pregnancy from the nurses and what their impressions were of the behavior of the nurses immediately after receiving ANC counseling (baseline) and two weeks postintervention (endline). The total scores for both perceptions and impressions increased significantly from baseline to endline. This suggests that the three-hour training found differences in the responses of pregnant women for that particular setting in this study.
Perceptions of receiving information on danger signs of pregnancy by pregnant women Regarding the perceptions of receiving information on the danger signs of pregnancy, the perception scores for all eight danger signs increased significantly from the baseline to the endline. This indicates that the behaviors of the nurses were influenced by the three-hour training, which consequently affected the pregnant women’s perceptions of receiving information on the danger signs of pregnancy as well as their impressions of the caring behaviors of the nurses. In terms of educational background of the pregnant 21
women in this study compared with that in a previous Tanzania survey (MoHCDGEC, MoH, NBS, OCGS, and ICF, 2016), the present data indicate that the percentage of pregnant women with No education or Incomplete primary school was 30% less than that of the previous Tanzania survey. In the present study, another possible reason for the increased perception of danger signs of pregnancy by the pregnant women was related to the distributed ‘Nne na Tano’ booklet to each pregnant woman at the ANC counseling. Jennings et al. (2010) conducted a pre-post test randomized group design study in Benin; 14 public health maternity clinics were randomized to either the intervention arm or the control arm. The type of intervention was a training program on counseling for nurse-midwives using job aids and interpersonal communication at ANC. The study previously evaluated ANC counseling supported by job aids in Benin and measured the pregnant women’s knowledge of the messages related to maternal and newborn care by exit interview. The mean number of correct responses for all the topic areas which included danger signs and birth preparation improved significantly in the intervention arm compared with the control arm. Another study by Jennings et al. (2015) involved a pre-post test randomized group design in rural Benin which examined postnatal counseling supported by job aids after giving birth in the hospital. Women in the intervention arm received postnatal counseling using job aids by trained nursemidwives, whereas women in the control arm did not receive postnatal counseling. 22
Maternal knowledge was measured using an exit questionnaire at discharge, and 411 mother-newborn pairs were observed. Maternal knowledge improved significantly compared with the control arm. Job aids were also confirmed to be helpful for understanding and recalling information for both health providers and pregnant women (Leshabari, Koniz-Booher, Burkhalter, Hoffman, & Jennings, 2007; Kedenge et al, 2013). These findings show that job aids are effective materials for counseling between nurses and pregnant women. Duysburgh et al. (2013) previously surveyed and asked 611 pregnant women in rural Tanzanian about the danger signs of pregnancy. Seven of the eight danger signs fit with the present study. The highest percentage of pregnant women (58%) identified vaginal bleeding as a danger sign, whereas the lowest percentage of pregnant women (2.5%) identified difficulty in breathing as a danger sign. Information on vaginal bleeding was conveyed to 63.3% (baseline) and 82.9% (endline) of pregnant women. Information on difficulty in breathing was conveyed to 6.8% (baseline) and 5.3% (endline) of pregnant women. A comparison of the scores for the characteristics of pregnant women showed differences in proportion to their education level. In this previous study, 43% of the pregnant women were not formally educated or had not completed primary school. In the present study, only 6.8% (baseline) and 5.3% (endline) of pregnant women had not completed primary school. Several studies have also 23
reported the associations between women’s educational level and perceptions of birth preparedness (Kabakyenga, Östergren, Turyakira, & Pettersson, 2011; Duysburgh et al., 2013; Okereke et al., 2013). These findings suggest that more highly educated women may have a higher ability to acquire information regarding the danger signs of pregnancy.
Impressions of pregnant women on the caring behaviors of nurses The present scores of impressions on all six behaviors of nurses increased significantly from baseline to endline. Manongi et al. (2009) underscored the effectiveness of a workshop for health workers in improving the satisfaction level of the relationship between nurses and parents of children at the pediatric ward in a regional hospital in Tanzania. The children’s parents answered questionnaires before and after the workshop for nurses. The questionnaire asked about nurses’ politeness, respect, or dignity toward the parents. The satisfaction level of the parents showed some improvement, although this was not significant. Some nurses responded that their participation in the workshop changed their behavior toward parents. They felt more pleased to communicate with parents and they planned to listen more to the parents’ complaints after the workshop. One of the contents of this job aid-supported intervention was to provide knowledge of the basics of interpersonal communication, counseling skills, and a favorable attitude toward women. These changes, which were evident after attendance to the three-hour 24
training by the nurses in the present study, are likely to play an important role in changing their caring behaviors to pregnant women.
Research limitations and future perspectives As the data of this study consisted only of reactions of pregnant women, the evaluation of the changes in the practical skills and attitudes of nurses after the intervention was limited. This study had a short-term follow-up and involved a limited evaluation of the differences of sustained knowledge and caring behaviors. Regarding the knowledge of the participants, there was a limitation in the assessment of what influenced the differences because the participants in the endline received the short story booklet during ANC.
Conclusion The job aid-supported intervention during ANC counseling found differences in the responses of pregnant women in receiving information on the danger signs of pregnancy and in identifying the favorable caring behaviors of nurses to pregnant women.
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Declarations
List of abbreviations
Sustainable development goals (SDGs)
World Health Organization (WHO)
Antenatal care (ANC)
Focused antenatal care (FANC)
Birth preparedness and complication readiness (BP/CR)
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Conflict of Interest The authors declare that they have no conflicts of interest associated with this study.
Ethics approval and consent to participate The study was conducted based on the principles of ethics, namely, harmlessness, voluntarily participation, anonymity, and protection of privacy and personal information. Participation in the study was voluntary and written informed consent was obtained from all pregnant women. The participants received an explanation regarding their right to refuse or withdraw their consent, or to stop participating using the refusal form. Ethical approval was obtained from the Tanzania National Institute for Medical Research (NIMR) (Ref. NIMR/HQ/R.8c/Vol. IX/1604) and the Tanzania Commission for Science and Technology (COSTECH) (No. 2015-127-EF-2013-101). Ethical permission was also obtained from the Ethics Committee of St. Luke’s International University, Japan (Approval number: 15 - 007).
Funding This research was supported by a grant from the Japan Society for the Promotion of Science (JSPS), B. Asia-Africa Science Platforms (2015-2018). Availability of data and materials 27
The datasets supporting the conclusions of this article are included within the article.
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References
Duysburgh, E., Ye, M., Williams, A., Massawe, S., Sie, A., Williams, J., . . . Temmerman, M. (2013). Counselling on and women's awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania. Tropical Medicine & International Health, 18(12), 1498-1509.
Harvey, S. A., Jennings, L., Chinyama, M., Masaninga, F., Mulholland, K., & Bell, D. R. (2008). Improving community health worker use of malaria rapid diagnostic tests in Zambia: Package instructions, job aid and job aid-plus-training. Malaria Journal, 7(1), 160.
Jennings, L., Yebadokpo, A., Affo, J., & Agbogbe, M. (2015). Use of job aids to improve facility-based postnatal counseling and care in rural Benin. Maternal and Child Health Journal, 19(3), 557-565.
Jennings, L., Yebadokpo, A. S., Affo, J., & Agbogbe, M. (2010). Antenatal counseling in maternal and newborn care: Use of job aids to improve health worker performance and maternal understanding in Benin. BMC Pregnancy and Childbirth, 10(1), 75.
29
JHPIEGO. (2004a). Maternal and neonatal health programme birth preparedness and complication readiness: A matrix of shared responsibilities (original BP/CR matrix poster published in 2001. English introductory text revised in 2004). (). Maryland, USA: Johns Hopkins University for International Education in Gynecology and Obstetrics.
JHPIEGO. (2004b). Monitoring birth preparedness and complication readiness. tools and indicators for maternal and newborn health. Maryland, UAS: Johns Hopkins University for International Education in Gynecology and Obstetrics.
Kabakyenga, J. K., Östergren, P., Turyakira, E., & Pettersson, K. O. (2011). Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda. Reproductive Health, 8(1), 33.
Kahabuka, C., Kvåle, G., Moland, K. M., & Hinderaker, S. G. (2011). Why caretakers bypass primary health care facilities for child care-a case from rural Tanzania. BMC Health Services Research, 11(1), 315.
Kearns, A., Hurst, T., Caglia, J., Langer, A. (2014). Focused antenatal care in Tanzania Women and Health Initiative & Maternal Health Task Force, Harvard School of Public Health.
30
Kedenge, S. V., Kangwana, B. P., Waweru, E. W., Nyandigisi, A. J., Pandit, J., Brooker, S. J., . . . Goodman, C. A. (2013). Understanding the impact of subsidizing artemisinin-based combination therapies (ACTs) in the retail sector–results from focus group discussions in rural Kenya. PLoS One, 8(1), e54371.
Knebel E. (2000). The use of manual job aids by health care providers: What do we know? (issue paper). Bethesda, MD: QAP for USAID.
Lassi, Z. S., Haider, B. A., & Bhutta, Z. A. (2010). Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. The Cochrane Library,
Leshabari, S., Koniz-Booher, P., Burkhalter, B., Hoffman, M., & Jennings, L. (2007). Testing a PMTCT infant-feeding counseling program in Tanzania.
Manongi, R. N., Nasuwa, F. R., Mwangi, R., Reyburn, H., Poulsen, A., & Chandler, C. I. (2009). Conflicting priorities: Evaluation of an intervention to improve nurseparent relationships on a Tanzanian paediatric ward. Human Resources for Health, 7(1), 50.
Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], 31
National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. 2016. Tanzania demographic and health survey and malaria indicator survey (TDHS-MIS) 2015-16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, and ICF.
Mutiso, S., Qureshi, Z., & Kinuthia, J. (2008). Birth preparedness among antenatal clients. East African Medical Journal, 85(6), 275-283.
National Bureau of Statistics (NBS), Macro International. (2007). Service provision assessment survey 2006. Dar es Salaam, Tanzania: National Bureau of Statistics.
Nelissen, E., Ersdal, H., Mduma, E., Evjen-Olsen, B., Broerse, J., van Roosmalen, J., & Stekelenburg, J. (2015). Helping mothers survive bleeding after birth: Retention of knowledge, skills, and confidence 9 months after obstetric simulation-based training. BMC Pregnancy & Childbirth, 15, 190-015-0612-2. doi: 10.1186/s12884015-0612-2 [doi]
Okereke, E., Aradeon, S., Akerele, A., Tanko, M., Yisa, I., & Obonyo, B. (2013). Knowledge of safe motherhood among women in rural communities in northern Nigeria: Implications for maternal mortality reduction. Reproductive Health, 10(1), 57.
32
Pembe, A. B., Carlstedt, A., Urassa, D. P., Lindmark, G., Nyström, L., & Darj, E. (2010). Quality of antenatal care in rural Tanzania: Counselling on pregnancy danger signs. BMC Pregnancy and Childbirth, 10(1), 35.
Pembe, A. B., Urassa, D. P., Carlstedt, A., Lindmark, G., Nyström, L., & Darj, E. (2009). Rural Tanzanian women's awareness of danger signs of obstetric complications. BMC Pregnancy and Childbirth, 9(1), 12.
Prost, A., Colbourn, T., Seward, N., Azad, K., Coomarasamy, A., Copas, A., . . .Lewycka, S. (2013). Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: A systematic review and meta-analysis. The Lancet, 381(9879), 1736-1746.
Rajabu, M. (2015). Official hospital statistics, annual report 2014. Tanga, Tanzania: The Anglican Diocese of Tanga, Hospital Management Team.
Shimpuku, Y., & Madeni, F. E. (2014). Nne na Tano [booklet]. Japan: St. Luke’s International University.
Solnes Miltenburg, A., Lambermon, F., Hamelink, C., & Meguid, T. (2016). Maternity care and human rights: What do women think? BMC International Health and Human Rights, 16(1), 17-016-0091-1. doi:10.1186/s12914-016-0091-1 33
Soubeiga, D., Gauvin, L., Hatem, M. A., & Johri, M. (2014). Birth preparedness and complication readiness (BPCR) interventions to reduce maternal and neonatal mortality in developing countries: Systematic review and meta-analysis. BMC Pregnancy and Childbirth, 14(1), 129.
Streiner, D. L. (1994). Figuring out factors: The use and misuse of factor analysis. The Canadian Journal of Psychiatry, 39(3), 135-140.
Thaddeus, S., & Maine, D. (1994). Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), 1091-1110.
Urassa, D. P., Pembe, A. B., & Mganga, F. (2012). Birth preparedness and complication readiness among women in Mpwapwa district, Tanzania. Tanzania Journal of Health Research, 14(1)
World Health Organization. (2015a). Health in 2015: From MDGs, millennium development goals to SDGs, sustainable development goals. WHO Library Cataloguing-in-Publication Data.
World Health Organization. (2015b). WHO recommendations on health promotion interventions for maternal and newborn health. WHO Library Cataloguing-inPublication Data. 34
World Health Organization. Department of Making Pregnancy Safer, & World Health Organization. (2010). Counselling for maternal and newborn health care: A handbook for building skills World Health Organization.
World Health Organization. (2006). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice. Geneva Switzerland: World Health Organization.
World Health Organization. Reproductive Health. (2003). Pregnancy, childbirth, postpartum, and newborn care: A guide for essential practice World Health Organization.
35
Box 1. Program contents for each educational goal Goal 1
1. To increase the knowledge of nurses regarding birth preparedness and danger signs during pregnancy
Contents
-
To provide information about a short statistical update on reducing maternal mortality in Sub-Sahara African countries – using the BP/CR concept
-
To share a short story: “Nne na Tano” about birth preparedness and danger signs of pregnancy
-
To ensure the importance of practicing birth preparedness and acquiring knowledge of the danger signs of pregnancy through the story
Methods
-
Lecture
-
Sharing a story
Goal 2
2. To improve knowledge of counseling skills at ANC
Contents
-
Basics of interpersonal communication and counseling skills, favorable attitude toward women - the role of the counselor
-
Role play exercise on explaining about birth preparedness and the danger signs to pregnant women using the job aid of the story “Nne na Tano” at ANC
Methods
Goals 3, 4
-
Lecture
-
Role play
3. To change the behavior of women when performing counseling at ANC 4. To enhance the quality of counseling during ANC to pregnant women.
Contents
-
Group discussion on how to explain more about the danger signs of pregnancy using the job aid at ANC
-
Group discussion on how to develop an action plan at their facility and how to implement this plan
Method
-
Discussion by participants
36
Table 1. Demographic characteristics of pregnant women at baseline and endline (N = 318)
Age: M [SD] years
Baseline
Endline
n = 148
n = 170
n (%)
n (%)
27.49 [6.879]
26.11 [6.244]
16-19
14
(9.5)
22
(12.9)
20-29
77
(52.0)
101
(59.4)
30-39
49
(33.1)
41
(24.1)
40-50
8
(5.4)
5
(1.6)
10
(6.8)
9
(5.3)
Primary school
94
(63.5)
112
(65.9)
Ordinary secondary school
38
(25.7)
41
(24.1)
6
(4.1)
8
(4.8)
Primigravida
50
(34.0)
57
(33.5)
Multigravida
97
(66.0)
113
(66.5)
1
31
(21.4)
49
(29.0)
2-3
87
(60.0)
92
(54.4)
4+
27
(18.6)
28
(16.6)
χ2-test
p-value
5.048
0.168
1.301
0.861
0.008
0.928
2.387
0.303
Educational level No education or Incomplete primary school
Advanced secondary school or above Parity
No. of times of visiting ANC clinic
ANC, antenatal care
37
Table 2. Perceptions of receiving information on danger signs of pregnancy by pregnant women at baseline and endline
Information on danger signs provided by nurses (0-8)
Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
4.92 [2.99]
6.66 [2.38]
t-test
X2-test
p-value
5.646
Yes
No
Yes
No
n (%)
n (%)
n (%)
n (%)
0.000
Vaginal bleeding
93 (63.3)
54 (36.7)
141 (82.9)
29 (17.1)
15.791
0.000
Severe headache with blurred vision
95 (64.6)
52 (35.4)
138 (81.2)
32 (18.8)
11.087
0.001
Fits / Convulsion
68 (45.9)
80 (54.1)
122 (72.2)
47 (27.8)
22.630
0.000
Difficulty in breathing
86 (59.3)
59 (40.7)
134 (79.8)
34 (20.2)
15.587
0.000
105 (72.4)
40 (27.6)
155 (91.7)
14
(8.3)
20.419
0.000
Too weak to get out of bed
77 (52.4)
70 (47.6)
130 (76.5)
40 (23.5)
20.189
0.000
Water breaking
86 (58.1)
62 (41.9)
139 (82.2)
30 (17.8)
22.322
0.000
Abdominal pain
112 (75.7)
36 (24.3)
154 (90.6)
16
12.863
0.000
Fever
(9.4)
Table 3. Impressions of pregnant women on caring behaviors of nurses at baseline and endline Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
26.17 [11.19]
Kind (1-5)
t-test
p-value
27.63 [6.81]
4.299
0.000
4.36 [0.73]
4.59 [0.42]
2.730
0.007
Respectful (1-5)
4.38 [0.59]
4.66 [0.24]
3.781
0.000
Reliable (1-5)
4.33 [0.51]
4.64 [0.33]
4.278
0.000
Careful (1-5)
4.38 [0.59]
4.66 [0.31]
3.648
0.000
Understanding (1-5)
4.40 [0.49]
4.62 [0.32]
2.997
0.003
Warm (1-5)
4.24 [1.20]
4.48 [0.50]
2.274
0.024
Impression on caring behavior of nurses (6-30)
Box 1. Program Contents for Each Educational Goal Goal 1
5. To increase the knowledge of nurses regarding birth preparedness and danger signs during pregnancy.
Contents
-
To provide information about a short statistical update on reducing maternal mortality in Sub-Sahara African countries – using the BP/CR concept.
-
To share a short story: “Nne na Tano” about birth preparedness and danger signs of pregnancy.
-
To ensure the importance of practicing of birth preparedness and acquiring knowledge of the danger signs of pregnancy through the story.
Methods
-
Lecture
-
Sharing a story
39
Goal 2
6. To improve knowledge of counseling skills at ANC.
Contents
-
Basics of interpersonal communication and counseling skills, favorable attitude toward women - the role of the counselor
-
Role play exercise on explaining about birth preparedness and the danger signs to pregnant women using the job aid of the story “Nne na Tano” at ANC
Methods
Goals 3, 4
-
Lecture
-
Role play
7. To change the behavior of women when performing counseling at ANC. 8. To enhance the quality of counseling during ANC to pregnant women.
Contents
-
Group discussion of how to explain more about the danger signs of pregnancy using the job aid at ANC
-
Group discussion of how to develop an action plan at their facility and how to implement this plan.
Method
-
Discussion by participants
40
Table 1. Demographic characteristics of pregnant women at baseline and endline (N = 318)
Age: M [SD] years
Baseline
Endline
n = 148
n = 170
n (%)
n (%)
27.49 [6.879]
26.11 [6.244]
16-19
14
(9.5)
22
(12.9)
20-29
77
(52.0)
101
(59.4)
30-39
49
(33.1)
41
(24.1)
40-50
8
(5.4)
5
(1.6)
10
(6.8)
9
(5.3)
Primary school
94
(63.5)
112
(65.9)
Ordinary secondary school
38
(25.7)
41
(24.1)
6
(4.1)
8
(4.8)
Primigravida
50
(34.0)
57
(33.5)
Multigravida
97
(66.0)
113
(66.5)
1
31
(21.4)
49
(29.0)
2-3
87
(60.0)
92
(54.4)
4+
27
(18.6)
28
(16.6)
χ2-test
p-value
5.048
0.168
1.301
0.861
0.008
0.928
2.387
0.303
Educational level No education or Incomplete primary school
Advanced secondary school or above Parity
No. of times of visiting ANC clinic
ANC, antenatal care
41
Table 2. Perceptions of receiving information on danger signs of pregnancy by pregnant women at baseline and endline
Information on danger signs provided by nurses (0-8)
Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
4.92 [2.99]
6.66 [2.38]
t-test
X2-test
p-value
5.646
Yes
No
Yes
No
n (%)
n (%)
n (%)
n (%)
0.000
Vaginal bleeding
93 (63.3)
54 (36.7)
141 (82.9)
29 (17.1)
15.791
0.000
Severe headache with blurred vision
95 (64.6)
52 (35.4)
138 (81.2)
32 (18.8)
11.087
0.001
Fits / Convulsion
68 (45.9)
80 (54.1)
122 (72.2)
47 (27.8)
22.630
0.000
Difficulty in breathing
86 (59.3)
59 (40.7)
134 (79.8)
34 (20.2)
15.587
0.000
105 (72.4)
40 (27.6)
155 (91.7)
14
(8.3)
20.419
0.000
Too weak to get out of bed
77 (52.4)
70 (47.6)
130 (76.5)
40 (23.5)
20.189
0.000
Water breaking
86 (58.1)
62 (41.9)
139 (82.2)
30 (17.8)
22.322
0.000
Abdominal pain
112 (75.7)
36 (24.3)
154 (90.6)
16
12.863
0.000
Fever
(9.4)
Table 3. Impressions of pregnant women on caring behaviors of nurses at baseline and endline Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
26.17 [11.19]
Kind (1-5)
t-test
p-value
27.63 [6.81]
4.299
0.000
4.36 [0.73]
4.59 [0.42]
2.730
0.007
Respectful (1-5)
4.38 [0.59]
4.66 [0.24]
3.781
0.000
Reliable (1-5)
4.33 [0.51]
4.64 [0.33]
4.278
0.000
Careful (1-5)
4.38 [0.59]
4.66 [0.31]
3.648
0.000
Understanding (1-5)
4.40 [0.49]
4.62 [0.32]
2.997
0.003
Warm (1-5)
4.24 [1.20]
4.48 [0.50]
2.274
0.024
Impression on caring behavior of nurses (6-30)
Conflict of interest: The authors declare that there are no conflicts of interest associated with this study.
Funding Source: Japan Society for the Promotion of Science (JSPS) Core-to-core program, Asia-Africa Science Platforms (2015-2018)
Ethical consideration: The study was conducted based on the principles of ethics, namely, harmlessness, voluntarily participation, anonymity, and protection of privacy and personal information. Ethical approval was obtained from the Tanzania National Institute for Medical Research 43
(NIMR) (Ref. NIMR/HQ/R.8c/Vol. IX/1604) and the Tanzania Commission for Science and Technology (COSTECH) (No. 2015-127-EF-2013-101). Ethical permission was also obtained from the Ethics Committee of St. Luke’s International University, Japan (Approval number: 15 - 007).
Acknowledgements: We thank all participants who shared their valuable time for this project. We are indebted to Dr. Edward F. Barroga (http://orcid.org/0000-0002-8920-2607; Academic Advisor/Mentor, Academic Writing Desk, St. Luke’s International University; Associate Professor and Senior Medical Editor, Tokyo Medical University), for his editorial review and helpful advice regarding our manuscript.
44
S2214-1391(17)30098-7 https://doi.org/10.1016/j.ijans.2018.11.005 IJANS 123
To appear in:
International Journal of Africa Nursing Sciences
Received Date: Revised Date: Accepted Date:
5 November 2017 14 November 2018 22 November 2018
Please cite this article as: M. Oka, S. Horiuchi, Y. Shimpuku, F. Madeni, S. Leshabari, Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania, International Journal of Africa Nursing Sciences (2018), doi: https://doi.org/10.1016/j.ijans.2018.11.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania Miyuki Oka, NM, MSN1) §, Shigeko Horiuchi, NM, PhD1) *, Yoko Shimpuku, NM, PhD1) *, Frida Madeni, NM, MSN2) *, Sebalda Leshabari, NM, PhD3) *
1)
St. Luke’s International University, Tokyo, Japan
2)
Korogwe District Hospital, Tanzania
3)
Muhimbili University of Health and Allied Sciences, Tanzania
*These authors contributed equally to this work
E-mail addresses: Miyuki Oka: [email protected] Shigeko Horiuchi: [email protected] Yoko Shimpuku: [email protected] Frida Madeni: [email protected] Sebalda Leshabari: [email protected]
§Correspondence:
Miyuki Oka
Graduate School of Nursing Science St. Luke’s International University 1
10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan E-mail: [email protected]
Authors’ information MO has 10 years of experience as a midwife and nurse in Japan. She has not only spent several months conducting research in Tanzania, but also served as a nurse tutor at a nursing and midwifery school in rural Tanzania.
SH is a professor and YS is an assistant professor of St. Luke’s International University specializing in midwifery. They have a long experience as researchers in the fields of nursing and midwifery.
FM is a midwife and district nurse officer at Korogwe District Hospital in rural Tanzania. She also has much experience as a researcher and midwife in clinical practice.
SL is the Dean of the School of Nursing in Muhimbili Health and Alliance University. She is a one of the leaders and authorities of midwifery education in Tanzania and has many years of experience as a midwife and a researcher. 2
All the authors are members of the Asia Africa Midwifery Research Center (AMReC) of St. Luke’s International University, Japan.
Authors’ contributions MO designed this study, conducted the educational program, acquired and analyzed data, and primarily wrote the manuscript. YS and FM supported the conduct the educational program. MO drafted the manuscript and SH, YS, FM, and SL made critical reviews and important revisions.
Acknowledgements The authors thank all the study participants, namely, the director, nurse administrators, nursemidwives, and antenatal care attendees in the hospital at Muheza in Tanzania. The authors also thank Dr. Edward Barroga for guidance in writing and revising the paper.
Abstract Background: In developing countries, nurses’ counseling during antenatal care (ANC) visits remains insufficient. We examined the effects of a job aid-supported intervention 3
on understanding the danger signs and improving the caring behaviors of nurses to women in rural Tanzania. Methods: This was a hospital-based research using a quasi-experimental pre-post study design. All nurses engaged in ANC counseling participated in a three-hour training covering counseling skills, pregnancy danger signs, use of a job aid, and quality of caring behaviors. The sample consisted of women who attended the ANC clinic and had no intrauterine fetal death. The primary outcome was perception of receiving information on the danger signs by women. The secondary outcome was impressions of women regarding the caring behaviors of nurses. Women answered questionnaires following ANC counseling (baseline) and two weeks postintervention (endline). Results: Of 318 women, 148 participated at baseline and 170 at endline. Regarding receiving information on danger signs, the mean baseline score of 4.92 (SD = 2.99) and the mean endline score of 6.66 (SD = 2.38) were significantly different (t = 5.646, p < .01). Regarding impressions of the nurses’ caring behavior, the mean total baseline score of 26.17 (range, 6-30; SD = 11.19) and the mean total endline score of 27.63 (SD = 6.81) were significantly different (t = 4.299, p < .01). Conclusion: The job aid-supported intervention during ANC counseling found differences in the responses to receiving information on the danger signs of pregnancy and in identifying the caring behaviors of nurses to women. 4
Keywords: Pre-post study design, Pregnancy, Teaching materials, Antenatal care, Health knowledge, Attitude, Practice, Tanzania
5
Background The third goal in the United Nations Sustainable Development Goals (SDGs) is to ensure healthy lives and promote the well-being of everyone at all age groups. This goal focuses on improving equity to meet the needs of women, children, and the poorest most disadvantaged people especially in developing countries (World Health Organization [WHO], 2015a). One of these countries is Tanzania which has a very high maternal death rate of 556 per 100,000 births (Ministry of Health, Community Development, Gender, Elderly and Children [MoHCDGEC], Ministry of Health [MoH], National Bureau of Statistics [NBS], Office of the Chief Government Statistician [OCGS], and ICF, 2016). Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries. Such delay has three aspects: delay in deciding to seek care, delay in reaching care, and delay in receiving skilled care (Thaddeus & Maine, 1994). These aspects commonly occur and become predictable by observing various situations surrounding pregnant women. Thus, women, their families, communities, health providers, and facilities may be able to prevent such delays by being carefully prepared. WHO states that birth preparedness and complication readiness (BP/CR) is an essential strategy in the provision of antenatal care (ANC) (WHO, 2015b). BP/CR is the process of planning for a safe birth and takes into consideration the desired 6
place for giving birth, the preferred birth attendant, and funds for any expenses related to birth and in case of complications. Interventions based on the BP/CR concept have been instituted to achieve reductions in maternal and neonatal deaths (JHPIEGO, 2004a; Lassi, Haider, & Bhutta, 2010; Prost et al. 2013; Soubeiga, Gauvin, Hatem, & Johri, 2014). In particular, systematic reviews of BP/CR interventions in populations of pregnant women living in developing counties have been conducted and BP/CR at the community level have been implemented (Lassi, Haider, & Bhutta, 2010; Prost et al. 2013; Soubeiga, Gauvin, Hatem, & Johri, 2014). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women, their families, and the community (Kearns, Hurst, Caglia, & Langer, 2014). The information or counseling provided may include various areas such as signs of complications and labor, emergency preparedness, preventive home practices, and support for seeking emergency facilities (WHO, 2006). Unfortunately, counseling practices during ANC visits remain poor and inefficient, particularly in Burkina Faso, Ghana, and Tanzania (Duysburgh et al., 2013) and in rural Tanzania (Pembe et al., 2010). In fact, Duysburgh et al. (2013) found that 39.5% of Tanzanian pregnant women were not informed of any danger signs of pregnancy, and that 30.0% of them could not state any danger signs of pregnancy following ANC counseling (Duysburgh et al., 2013). Pembe et al. (2010) suggested that 7
the poor performance of nurses in rural Tanzania could be due to the limited human resources, short ANC time, poor knowledge of the importance of counseling on BP/CR, and low motivation. Others have indicated that the poor outcome of counseling on pregnancy is also attributable to the poor awareness of the danger signs of pregnancy among women who have attended ANC (Mutiso, Qureshi, & Kinuthia, 2008). Moreover, in the description of women’s perception about maternity services in rural Tanzania, Miltenburg et al. (2016) found that pregnant women were occasionally afraid of the response of healthcare workers as this might come in the form of a scolding. This finding might have affected the women’s poor awareness of health information regarding pregnancy. A recent survey in Tanzania has shown that 98% of pregnant women visit ANC at least once, and only 51% visit ANC four times or more (MoHCDGEC, MoH, NBS, OCGS, and ICF, 2016). Notably, only 13% of facilities offering ANC had visual or job aids for educating women (NBS, 2007). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010). Job aids have been shown to be effective in 8
improving the performance of nurses (Knebel, 2000; Leshabari, Koniz-Booher, Burkhalter, Hoffman, & Jennings, 2007; Jennings, Yebadokpo, Affo, & Agbogbe, 2010). For instance, job aids have provided important information on infant feeding or how to perform malaria rapid diagnostic tests (Leshabari, Koniz-Booher, Burkhalter, Hoffman, & Jennings, 2007; Harvey, Jennings, Chinyama, Masaninga, & Mulholland, 2008). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care (Jennings, Yebadokpo, Affo, & Agbogbe, 2010). This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses. This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.
9
Methods
Study design This research used a quasi-experimental pre-post study design.
Setting After obtaining permission, this study was conducted in a hospital at Muheza district in the Tanga region of Tanzania. Muheza district is one of the eight districts in the Tanga region located in the northeastern part of Tanzania, and approximately 25 km from Tanga city. Muheza is served by 54 dispensaries, four health centers, and one district hospital (Kahabuka, Kvåle, Moland, & Hinderaker, 2011). In the setting hospital, there were 4,513 deliveries, 723 cesarean sections, 11 maternal deaths, and 67 neonatal deaths in 2014 (Rajabu, 2015).
Sample selection The study population consisted of all pregnant women who attended the ANC clinic during the study period and who understood Kiswahili as inclusion criteria. The exclusion criterion was pregnant women who had a diagnosis of intrauterine fetal death.
10
Sample size The minimum sample size providing usable data for analysis should be five times the number of variables (Streiner, 1994). The dropout rate was estimated as 30%, thus the approximate sample size needed was at least 124.
Study period This study was conducted from the end of June 2015 to the early part of August 2015.
Description of job aid-supported intervention The job aid-supported intervention training was conducted on July 4, 2015. All nurses (n = 29) who provide ANC counseling at the setting hospital participated in the training for three hours. The contents of each program goal are shown in Box 1. For this study, the first author (MO) developed the contents of the three-hour training on the basis of a simulation-based training (Nelissen et al., 2015), educational material on monitoring BR and CR (JHPIEGO, 2004b), and a handbook for counseling on maternal and newborn health care (WHO, 2010). The training covered various areas, namely, counseling skills, and preparations for childbirth and danger signs of pregnancy, use of the booklet “Nne na Tano” as a job aid, and quality of caring behavior. The training was called “Let’s talk!” (Zungmunza Vizuri) and involved a discussion about birth preparedness between 11
nurses and pregnant women or pregnant women and their relatives with the aim of improving the quality of life of all concerned. The co-authors (YS and FM) of this study developed a short story booklet called ‘Nne na Tano’ (Shimpuku & Madeni, 2014) based on BP/CR concepts written in Kiswahili. The booklet measures 15 x 21 cm, has 22 pages, and is printed in full color pictures for each page. This booklet describes a story about BP/CR. Nne and Tano are the two main pregnant women characters in the short story. Nne prepares well for her birth whereas Tano does not. The first two pages explain the booklet and the last two pages show the danger signs of pregnancy using pictures and bullet points.
Please insert Box 1 here.
Outcome measures: instruments The study measured two outcomes. The primary outcome was the perception of receiving information on the danger signs of pregnancy by pregnant women. The secondary outcome was the impression of pregnant women on the caring behavior of nurses. The first author (MO) developed the questionnaires for pregnant women in accordance with the study purpose. The items of these questionnaires were developed based the WHO guide on pregnancy, childbirth, postpartum and newborn care (WHO, 12
2003). The items of danger signs of pregnancy included vaginal bleeding, severe headache with blurred vision, fits / convulsion, difficult breathing, fever, too weak to get out of bed, water break, and abdominal pain. The items of the impression of pregnant women on the caring behavior of nurses asked pregnant women their impressions of the nurses’ behavior which included the following: kind, arrogant, respectful, abusive, understanding, and cold.
Translation process The questionnaire was developed in English and then translated to Kiswahili by the local co-author who had experience as a local midwife. Back translation to English was carried out by another experienced co-author to identify not only linguistic equivalence but also the conceptual and cultural equivalence (WHO, 2018; Maneesriwongul & Dixon, 2004).
Primary outcome: perception of receiving information on the danger signs of pregnancy by pregnant women A test was developed to estimate the perception of receiving information on the danger signs of pregnancy. The test consisted of eight items derived from the WHO guide on pregnancy, childbirth, postpartum and newborn care (WHO, 2003), and previous studies 13
(Pembe, 2009; Urassa, Pembe, & Mganga, 2012). These questions asked the pregnant women if they were provided proper information on the danger signs of pregnancy at their ANC visit: 0) no or 1) yes. The scores ranged from zero to eight points. A high score indicates that the nurses provided proper information.
Secondary outcome: impression of pregnant women on the caring behavior of nurses The questions for the secondary outcome consisted of six items developed on the basis of the counseling skills described in the handbook on Counseling for Maternal and Newborn Health Care (WHO, 2010). The six items gauged the impression of the pregnant women on the caring behavior of nurses from 1) strongly disagree to 5) strongly agree. The score range is from six to 30 points, with higher scores indicating a perception of a more positive and caring behavior by the nurses. One question [answerable by 0) no or 1) yes] was specifically included to confirm if pregnant women were encouraged by a nurse to attend the next ANC service. A score of 1) means that the nurse mentioned the next ANC service to the pregnant women.
Content validation The instruments were assessed for content validity by three experienced midwife researchers. The researchers encountered no problems with the description of the 14
primary and secondary outcomes used in this study; minor corrections were made for some questions such as adding some statements that are more suitable for their situation, changing some phrases for better understanding, and technical editing. Substantive changes were not made to the instruments.
Data collection The first author and co-author (FM) selected the eligible pregnant women as respondents from all the pregnant women who visited the clinic for a regular antenatal check-up during the study period. Then, they explained the study to the eligible pregnant women immediately after undergoing the ANC counseling. If the pregnant women gave their consent to participate, the first author and co-author (FM) immediately asked each woman the questions from the author-developed questionnaire and wrote down the pregnant women’s responses at that time. The questionnaires for the pregnant women were collected immediately after the ANC counseling (baseline) and two weeks after the job aid-supported intervention (endline). The data collection process at the endline was managed similarly to the data collection process at the baseline. Specifically, after the job aid-supported intervention, the questionnaires were managed similarly and also consisted of the same 19 items.
15
Data analysis Analysis of variance was used to compare the effects of the job aid-supported intervention using the average scores at baseline (after the ANC counseling) and endline (two weeks postintervention). Differences were analyzed by the unpaired t-test and chisquare test using SPSS version 22.0 for Windows.
Ethical consideration The study was conducted based on the principles of ethics such as harmlessness, voluntarily participation, anonymity, and protection of privacy and personal information. Participation in the study was voluntary and written informed consent was obtained from all pregnant women. The participants received an explanation regarding their right to refuse or withdraw their consent, or to stop participating using the refusal form. Ethical approval of this study was obtained from the Tanzania National Institute for Medical Research (NIMR) (Ref. NIMR/HQ/R.8c/Vol. IX/1604) and the Tanzania Commission for Science and Technology (COSTECH) (No. 2015-127-EF-2013-101). Ethical permission was also obtained from the Ethics Committee of St. Luke’s International University, Japan (Approval number: 15 - 007).
16
Results
All data from the pregnant women were collected immediately after they received ANC counseling (baseline; June 29, 2015 – July 3, 2015) and two weeks after the intervention (endline; July 21-31, 2015).
Demographic characteristics of pregnant women (Table 1) The total number of respondents in this study was 318 pregnant women. Of these 318 pregnant women, 148 participated at baseline and 170 participated at endline. The demographic characteristics of the pregnant women at baseline and endline are shown in Table 1. The ages ranged from 16 to 50 years at baseline, and from 18 to 45 years at endline. More than 50% of the participants were in their 20s and the participants in the next older group were in their 30s. Both groups had less than 10% of participants in their 40s. The highest educational level attained by most of the pregnant women was Primary school in both groups. This was followed by Ordinary secondary school, No education or Incomplete primary school, and Advanced secondary school or above. Over half of the pregnant women were multigravida women in both groups compared with primigravida women.
17
The highest number of times of choosing to visit the ANC clinic was two or three times in both groups. This was followed by one time, and then four times or more. There were no significant differences in the age, educational level, parity, and number of times of visiting the ANC clinic among the pregnant women between the two groups.
Please insert Table 1 here.
Perceptions of receiving information on danger signs of pregnancy by pregnant women (Table 2) The questionnaire consisted of eight-item questions. The questions asked whether the pregnant women received information on the danger signs of pregnancy from the nurses immediately after finishing the ANC counseling (baseline) and two weeks postintervention (endline) (Table 2). The mean scores of Information on danger signs provided by nurses were 4.92 [SD = 2.99] (baseline) and 6.66 [SD = 2.38] (endline), showing a significant difference (t = 5.646, p < .01). The chi-square test indicated that the percentages of pregnant women given information on all the individual danger signs were significantly different between the baseline and the endline (Table 2). The danger signs that had larger disparities between the two scores from the highest to the lowest were Fits / Convulsion (x2 = 22.630, p 18
< .01), Water breaking (x2 = 22.322, p < .01), Fever (x2 = 20.419, p < .01), and Too weak to get out of bed (x2 = 20.189, p < .01). In terms of the percentage of pregnant women who received (indicated in Table 2 as “Yes”) and who did not receive (“No”) information on danger signs, the danger signs Fits / Convulsion and Too weak to get out of bed showed a lower percentage for Yes at baseline than at endline. There was a large increase in the percentage of participants from baseline to endline reporting that they received (Yes) information on the danger signs Fits / Convulsion from 45.9% to 72.2% and Too weak to get out of bed from 52.4% to 76.5% (Table 2). Abdominal pain and Fever showed the highest percentage in pregnant women who received (Yes) such information both at baseline and at endline. Specifically, the percentage of pregnant women receiving information on Abdominal pain increased from 75.7% (baseline) to 90.6% (endline), and on Fever from 72.4% (baseline) to 91.7% (endline). Overall, the percentage of pregnant women receiving information on danger signs from nurses was higher at endline than at baseline.
Please insert Table 2 here.
19
Impressions of pregnant women on the caring behavior of nurses (Table 3) A comparison of the mean scores of impressions of pregnant women on the caring behavior of nurses at baseline and endline is shown in Table 3. The total scores ranged from six to 30 with a mean of 26.17 (SD = 11.19) at baseline and 27.63 (SD = 6.81) at endline, showing a significant difference (t = 4.299, p < .01). The impressions consisted of ideal caring behaviors toward pregnant women at ANC counseling, namely, being Kind, Respectful, Reliable, Careful, Understanding, and Warm (Table 3). The scores of all the impressions were significantly different between the baseline and the endline as shown by the t-test. Being Reliable showed the highest t value (t = 4.278, p < .01), followed by being (in descending order) Respectful (t = 3.781, p < .01), Careful (t = 3.648, p < .01), Understanding (t = 2.997, p < .01), Kind (t = 2.730, p < .01), and Warm (t = 2.274, p < .01). Taken together, the pregnant women showed higher mean scores of impressions on the caring behaviors of nurses at endline than at baseline.
Please insert Table 3 here.
20
Discussion
Pregnant women’s perspective on ANC counseling Pregnant women were asked whether they perceived receiving information on the danger signs of pregnancy from the nurses and what their impressions were of the behavior of the nurses immediately after receiving ANC counseling (baseline) and two weeks postintervention (endline). The total scores for both perceptions and impressions increased significantly from baseline to endline. This suggests that the three-hour training found differences in the responses of pregnant women for that particular setting in this study.
Perceptions of receiving information on danger signs of pregnancy by pregnant women Regarding the perceptions of receiving information on the danger signs of pregnancy, the perception scores for all eight danger signs increased significantly from the baseline to the endline. This indicates that the behaviors of the nurses were influenced by the three-hour training, which consequently affected the pregnant women’s perceptions of receiving information on the danger signs of pregnancy as well as their impressions of the caring behaviors of the nurses. In terms of educational background of the pregnant 21
women in this study compared with that in a previous Tanzania survey (MoHCDGEC, MoH, NBS, OCGS, and ICF, 2016), the present data indicate that the percentage of pregnant women with No education or Incomplete primary school was 30% less than that of the previous Tanzania survey. In the present study, another possible reason for the increased perception of danger signs of pregnancy by the pregnant women was related to the distributed ‘Nne na Tano’ booklet to each pregnant woman at the ANC counseling. Jennings et al. (2010) conducted a pre-post test randomized group design study in Benin; 14 public health maternity clinics were randomized to either the intervention arm or the control arm. The type of intervention was a training program on counseling for nurse-midwives using job aids and interpersonal communication at ANC. The study previously evaluated ANC counseling supported by job aids in Benin and measured the pregnant women’s knowledge of the messages related to maternal and newborn care by exit interview. The mean number of correct responses for all the topic areas which included danger signs and birth preparation improved significantly in the intervention arm compared with the control arm. Another study by Jennings et al. (2015) involved a pre-post test randomized group design in rural Benin which examined postnatal counseling supported by job aids after giving birth in the hospital. Women in the intervention arm received postnatal counseling using job aids by trained nursemidwives, whereas women in the control arm did not receive postnatal counseling. 22
Maternal knowledge was measured using an exit questionnaire at discharge, and 411 mother-newborn pairs were observed. Maternal knowledge improved significantly compared with the control arm. Job aids were also confirmed to be helpful for understanding and recalling information for both health providers and pregnant women (Leshabari, Koniz-Booher, Burkhalter, Hoffman, & Jennings, 2007; Kedenge et al, 2013). These findings show that job aids are effective materials for counseling between nurses and pregnant women. Duysburgh et al. (2013) previously surveyed and asked 611 pregnant women in rural Tanzanian about the danger signs of pregnancy. Seven of the eight danger signs fit with the present study. The highest percentage of pregnant women (58%) identified vaginal bleeding as a danger sign, whereas the lowest percentage of pregnant women (2.5%) identified difficulty in breathing as a danger sign. Information on vaginal bleeding was conveyed to 63.3% (baseline) and 82.9% (endline) of pregnant women. Information on difficulty in breathing was conveyed to 6.8% (baseline) and 5.3% (endline) of pregnant women. A comparison of the scores for the characteristics of pregnant women showed differences in proportion to their education level. In this previous study, 43% of the pregnant women were not formally educated or had not completed primary school. In the present study, only 6.8% (baseline) and 5.3% (endline) of pregnant women had not completed primary school. Several studies have also 23
reported the associations between women’s educational level and perceptions of birth preparedness (Kabakyenga, Östergren, Turyakira, & Pettersson, 2011; Duysburgh et al., 2013; Okereke et al., 2013). These findings suggest that more highly educated women may have a higher ability to acquire information regarding the danger signs of pregnancy.
Impressions of pregnant women on the caring behaviors of nurses The present scores of impressions on all six behaviors of nurses increased significantly from baseline to endline. Manongi et al. (2009) underscored the effectiveness of a workshop for health workers in improving the satisfaction level of the relationship between nurses and parents of children at the pediatric ward in a regional hospital in Tanzania. The children’s parents answered questionnaires before and after the workshop for nurses. The questionnaire asked about nurses’ politeness, respect, or dignity toward the parents. The satisfaction level of the parents showed some improvement, although this was not significant. Some nurses responded that their participation in the workshop changed their behavior toward parents. They felt more pleased to communicate with parents and they planned to listen more to the parents’ complaints after the workshop. One of the contents of this job aid-supported intervention was to provide knowledge of the basics of interpersonal communication, counseling skills, and a favorable attitude toward women. These changes, which were evident after attendance to the three-hour 24
training by the nurses in the present study, are likely to play an important role in changing their caring behaviors to pregnant women.
Research limitations and future perspectives As the data of this study consisted only of reactions of pregnant women, the evaluation of the changes in the practical skills and attitudes of nurses after the intervention was limited. This study had a short-term follow-up and involved a limited evaluation of the differences of sustained knowledge and caring behaviors. Regarding the knowledge of the participants, there was a limitation in the assessment of what influenced the differences because the participants in the endline received the short story booklet during ANC.
Conclusion The job aid-supported intervention during ANC counseling found differences in the responses of pregnant women in receiving information on the danger signs of pregnancy and in identifying the favorable caring behaviors of nurses to pregnant women.
25
Declarations
List of abbreviations
Sustainable development goals (SDGs)
World Health Organization (WHO)
Antenatal care (ANC)
Focused antenatal care (FANC)
Birth preparedness and complication readiness (BP/CR)
26
Conflict of Interest The authors declare that they have no conflicts of interest associated with this study.
Ethics approval and consent to participate The study was conducted based on the principles of ethics, namely, harmlessness, voluntarily participation, anonymity, and protection of privacy and personal information. Participation in the study was voluntary and written informed consent was obtained from all pregnant women. The participants received an explanation regarding their right to refuse or withdraw their consent, or to stop participating using the refusal form. Ethical approval was obtained from the Tanzania National Institute for Medical Research (NIMR) (Ref. NIMR/HQ/R.8c/Vol. IX/1604) and the Tanzania Commission for Science and Technology (COSTECH) (No. 2015-127-EF-2013-101). Ethical permission was also obtained from the Ethics Committee of St. Luke’s International University, Japan (Approval number: 15 - 007).
Funding This research was supported by a grant from the Japan Society for the Promotion of Science (JSPS), B. Asia-Africa Science Platforms (2015-2018). Availability of data and materials 27
The datasets supporting the conclusions of this article are included within the article.
28
References
Duysburgh, E., Ye, M., Williams, A., Massawe, S., Sie, A., Williams, J., . . . Temmerman, M. (2013). Counselling on and women's awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania. Tropical Medicine & International Health, 18(12), 1498-1509.
Harvey, S. A., Jennings, L., Chinyama, M., Masaninga, F., Mulholland, K., & Bell, D. R. (2008). Improving community health worker use of malaria rapid diagnostic tests in Zambia: Package instructions, job aid and job aid-plus-training. Malaria Journal, 7(1), 160.
Jennings, L., Yebadokpo, A., Affo, J., & Agbogbe, M. (2015). Use of job aids to improve facility-based postnatal counseling and care in rural Benin. Maternal and Child Health Journal, 19(3), 557-565.
Jennings, L., Yebadokpo, A. S., Affo, J., & Agbogbe, M. (2010). Antenatal counseling in maternal and newborn care: Use of job aids to improve health worker performance and maternal understanding in Benin. BMC Pregnancy and Childbirth, 10(1), 75.
29
JHPIEGO. (2004a). Maternal and neonatal health programme birth preparedness and complication readiness: A matrix of shared responsibilities (original BP/CR matrix poster published in 2001. English introductory text revised in 2004). (). Maryland, USA: Johns Hopkins University for International Education in Gynecology and Obstetrics.
JHPIEGO. (2004b). Monitoring birth preparedness and complication readiness. tools and indicators for maternal and newborn health. Maryland, UAS: Johns Hopkins University for International Education in Gynecology and Obstetrics.
Kabakyenga, J. K., Östergren, P., Turyakira, E., & Pettersson, K. O. (2011). Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda. Reproductive Health, 8(1), 33.
Kahabuka, C., Kvåle, G., Moland, K. M., & Hinderaker, S. G. (2011). Why caretakers bypass primary health care facilities for child care-a case from rural Tanzania. BMC Health Services Research, 11(1), 315.
Kearns, A., Hurst, T., Caglia, J., Langer, A. (2014). Focused antenatal care in Tanzania Women and Health Initiative & Maternal Health Task Force, Harvard School of Public Health.
30
Kedenge, S. V., Kangwana, B. P., Waweru, E. W., Nyandigisi, A. J., Pandit, J., Brooker, S. J., . . . Goodman, C. A. (2013). Understanding the impact of subsidizing artemisinin-based combination therapies (ACTs) in the retail sector–results from focus group discussions in rural Kenya. PLoS One, 8(1), e54371.
Knebel E. (2000). The use of manual job aids by health care providers: What do we know? (issue paper). Bethesda, MD: QAP for USAID.
Lassi, Z. S., Haider, B. A., & Bhutta, Z. A. (2010). Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. The Cochrane Library,
Leshabari, S., Koniz-Booher, P., Burkhalter, B., Hoffman, M., & Jennings, L. (2007). Testing a PMTCT infant-feeding counseling program in Tanzania.
Manongi, R. N., Nasuwa, F. R., Mwangi, R., Reyburn, H., Poulsen, A., & Chandler, C. I. (2009). Conflicting priorities: Evaluation of an intervention to improve nurseparent relationships on a Tanzanian paediatric ward. Human Resources for Health, 7(1), 50.
Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], 31
National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. 2016. Tanzania demographic and health survey and malaria indicator survey (TDHS-MIS) 2015-16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, and ICF.
Mutiso, S., Qureshi, Z., & Kinuthia, J. (2008). Birth preparedness among antenatal clients. East African Medical Journal, 85(6), 275-283.
National Bureau of Statistics (NBS), Macro International. (2007). Service provision assessment survey 2006. Dar es Salaam, Tanzania: National Bureau of Statistics.
Nelissen, E., Ersdal, H., Mduma, E., Evjen-Olsen, B., Broerse, J., van Roosmalen, J., & Stekelenburg, J. (2015). Helping mothers survive bleeding after birth: Retention of knowledge, skills, and confidence 9 months after obstetric simulation-based training. BMC Pregnancy & Childbirth, 15, 190-015-0612-2. doi: 10.1186/s12884015-0612-2 [doi]
Okereke, E., Aradeon, S., Akerele, A., Tanko, M., Yisa, I., & Obonyo, B. (2013). Knowledge of safe motherhood among women in rural communities in northern Nigeria: Implications for maternal mortality reduction. Reproductive Health, 10(1), 57.
32
Pembe, A. B., Carlstedt, A., Urassa, D. P., Lindmark, G., Nyström, L., & Darj, E. (2010). Quality of antenatal care in rural Tanzania: Counselling on pregnancy danger signs. BMC Pregnancy and Childbirth, 10(1), 35.
Pembe, A. B., Urassa, D. P., Carlstedt, A., Lindmark, G., Nyström, L., & Darj, E. (2009). Rural Tanzanian women's awareness of danger signs of obstetric complications. BMC Pregnancy and Childbirth, 9(1), 12.
Prost, A., Colbourn, T., Seward, N., Azad, K., Coomarasamy, A., Copas, A., . . .Lewycka, S. (2013). Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: A systematic review and meta-analysis. The Lancet, 381(9879), 1736-1746.
Rajabu, M. (2015). Official hospital statistics, annual report 2014. Tanga, Tanzania: The Anglican Diocese of Tanga, Hospital Management Team.
Shimpuku, Y., & Madeni, F. E. (2014). Nne na Tano [booklet]. Japan: St. Luke’s International University.
Solnes Miltenburg, A., Lambermon, F., Hamelink, C., & Meguid, T. (2016). Maternity care and human rights: What do women think? BMC International Health and Human Rights, 16(1), 17-016-0091-1. doi:10.1186/s12914-016-0091-1 33
Soubeiga, D., Gauvin, L., Hatem, M. A., & Johri, M. (2014). Birth preparedness and complication readiness (BPCR) interventions to reduce maternal and neonatal mortality in developing countries: Systematic review and meta-analysis. BMC Pregnancy and Childbirth, 14(1), 129.
Streiner, D. L. (1994). Figuring out factors: The use and misuse of factor analysis. The Canadian Journal of Psychiatry, 39(3), 135-140.
Thaddeus, S., & Maine, D. (1994). Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), 1091-1110.
Urassa, D. P., Pembe, A. B., & Mganga, F. (2012). Birth preparedness and complication readiness among women in Mpwapwa district, Tanzania. Tanzania Journal of Health Research, 14(1)
World Health Organization. (2015a). Health in 2015: From MDGs, millennium development goals to SDGs, sustainable development goals. WHO Library Cataloguing-in-Publication Data.
World Health Organization. (2015b). WHO recommendations on health promotion interventions for maternal and newborn health. WHO Library Cataloguing-inPublication Data. 34
World Health Organization. Department of Making Pregnancy Safer, & World Health Organization. (2010). Counselling for maternal and newborn health care: A handbook for building skills World Health Organization.
World Health Organization. (2006). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice. Geneva Switzerland: World Health Organization.
World Health Organization. Reproductive Health. (2003). Pregnancy, childbirth, postpartum, and newborn care: A guide for essential practice World Health Organization.
35
Box 1. Program contents for each educational goal Goal 1
1. To increase the knowledge of nurses regarding birth preparedness and danger signs during pregnancy
Contents
-
To provide information about a short statistical update on reducing maternal mortality in Sub-Sahara African countries – using the BP/CR concept
-
To share a short story: “Nne na Tano” about birth preparedness and danger signs of pregnancy
-
To ensure the importance of practicing birth preparedness and acquiring knowledge of the danger signs of pregnancy through the story
Methods
-
Lecture
-
Sharing a story
Goal 2
2. To improve knowledge of counseling skills at ANC
Contents
-
Basics of interpersonal communication and counseling skills, favorable attitude toward women - the role of the counselor
-
Role play exercise on explaining about birth preparedness and the danger signs to pregnant women using the job aid of the story “Nne na Tano” at ANC
Methods
Goals 3, 4
-
Lecture
-
Role play
3. To change the behavior of women when performing counseling at ANC 4. To enhance the quality of counseling during ANC to pregnant women.
Contents
-
Group discussion on how to explain more about the danger signs of pregnancy using the job aid at ANC
-
Group discussion on how to develop an action plan at their facility and how to implement this plan
Method
-
Discussion by participants
36
Table 1. Demographic characteristics of pregnant women at baseline and endline (N = 318)
Age: M [SD] years
Baseline
Endline
n = 148
n = 170
n (%)
n (%)
27.49 [6.879]
26.11 [6.244]
16-19
14
(9.5)
22
(12.9)
20-29
77
(52.0)
101
(59.4)
30-39
49
(33.1)
41
(24.1)
40-50
8
(5.4)
5
(1.6)
10
(6.8)
9
(5.3)
Primary school
94
(63.5)
112
(65.9)
Ordinary secondary school
38
(25.7)
41
(24.1)
6
(4.1)
8
(4.8)
Primigravida
50
(34.0)
57
(33.5)
Multigravida
97
(66.0)
113
(66.5)
1
31
(21.4)
49
(29.0)
2-3
87
(60.0)
92
(54.4)
4+
27
(18.6)
28
(16.6)
χ2-test
p-value
5.048
0.168
1.301
0.861
0.008
0.928
2.387
0.303
Educational level No education or Incomplete primary school
Advanced secondary school or above Parity
No. of times of visiting ANC clinic
ANC, antenatal care
37
Table 2. Perceptions of receiving information on danger signs of pregnancy by pregnant women at baseline and endline
Information on danger signs provided by nurses (0-8)
Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
4.92 [2.99]
6.66 [2.38]
t-test
X2-test
p-value
5.646
Yes
No
Yes
No
n (%)
n (%)
n (%)
n (%)
0.000
Vaginal bleeding
93 (63.3)
54 (36.7)
141 (82.9)
29 (17.1)
15.791
0.000
Severe headache with blurred vision
95 (64.6)
52 (35.4)
138 (81.2)
32 (18.8)
11.087
0.001
Fits / Convulsion
68 (45.9)
80 (54.1)
122 (72.2)
47 (27.8)
22.630
0.000
Difficulty in breathing
86 (59.3)
59 (40.7)
134 (79.8)
34 (20.2)
15.587
0.000
105 (72.4)
40 (27.6)
155 (91.7)
14
(8.3)
20.419
0.000
Too weak to get out of bed
77 (52.4)
70 (47.6)
130 (76.5)
40 (23.5)
20.189
0.000
Water breaking
86 (58.1)
62 (41.9)
139 (82.2)
30 (17.8)
22.322
0.000
Abdominal pain
112 (75.7)
36 (24.3)
154 (90.6)
16
12.863
0.000
Fever
(9.4)
Table 3. Impressions of pregnant women on caring behaviors of nurses at baseline and endline Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
26.17 [11.19]
Kind (1-5)
t-test
p-value
27.63 [6.81]
4.299
0.000
4.36 [0.73]
4.59 [0.42]
2.730
0.007
Respectful (1-5)
4.38 [0.59]
4.66 [0.24]
3.781
0.000
Reliable (1-5)
4.33 [0.51]
4.64 [0.33]
4.278
0.000
Careful (1-5)
4.38 [0.59]
4.66 [0.31]
3.648
0.000
Understanding (1-5)
4.40 [0.49]
4.62 [0.32]
2.997
0.003
Warm (1-5)
4.24 [1.20]
4.48 [0.50]
2.274
0.024
Impression on caring behavior of nurses (6-30)
Box 1. Program Contents for Each Educational Goal Goal 1
5. To increase the knowledge of nurses regarding birth preparedness and danger signs during pregnancy.
Contents
-
To provide information about a short statistical update on reducing maternal mortality in Sub-Sahara African countries – using the BP/CR concept.
-
To share a short story: “Nne na Tano” about birth preparedness and danger signs of pregnancy.
-
To ensure the importance of practicing of birth preparedness and acquiring knowledge of the danger signs of pregnancy through the story.
Methods
-
Lecture
-
Sharing a story
39
Goal 2
6. To improve knowledge of counseling skills at ANC.
Contents
-
Basics of interpersonal communication and counseling skills, favorable attitude toward women - the role of the counselor
-
Role play exercise on explaining about birth preparedness and the danger signs to pregnant women using the job aid of the story “Nne na Tano” at ANC
Methods
Goals 3, 4
-
Lecture
-
Role play
7. To change the behavior of women when performing counseling at ANC. 8. To enhance the quality of counseling during ANC to pregnant women.
Contents
-
Group discussion of how to explain more about the danger signs of pregnancy using the job aid at ANC
-
Group discussion of how to develop an action plan at their facility and how to implement this plan.
Method
-
Discussion by participants
40
Table 1. Demographic characteristics of pregnant women at baseline and endline (N = 318)
Age: M [SD] years
Baseline
Endline
n = 148
n = 170
n (%)
n (%)
27.49 [6.879]
26.11 [6.244]
16-19
14
(9.5)
22
(12.9)
20-29
77
(52.0)
101
(59.4)
30-39
49
(33.1)
41
(24.1)
40-50
8
(5.4)
5
(1.6)
10
(6.8)
9
(5.3)
Primary school
94
(63.5)
112
(65.9)
Ordinary secondary school
38
(25.7)
41
(24.1)
6
(4.1)
8
(4.8)
Primigravida
50
(34.0)
57
(33.5)
Multigravida
97
(66.0)
113
(66.5)
1
31
(21.4)
49
(29.0)
2-3
87
(60.0)
92
(54.4)
4+
27
(18.6)
28
(16.6)
χ2-test
p-value
5.048
0.168
1.301
0.861
0.008
0.928
2.387
0.303
Educational level No education or Incomplete primary school
Advanced secondary school or above Parity
No. of times of visiting ANC clinic
ANC, antenatal care
41
Table 2. Perceptions of receiving information on danger signs of pregnancy by pregnant women at baseline and endline
Information on danger signs provided by nurses (0-8)
Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
4.92 [2.99]
6.66 [2.38]
t-test
X2-test
p-value
5.646
Yes
No
Yes
No
n (%)
n (%)
n (%)
n (%)
0.000
Vaginal bleeding
93 (63.3)
54 (36.7)
141 (82.9)
29 (17.1)
15.791
0.000
Severe headache with blurred vision
95 (64.6)
52 (35.4)
138 (81.2)
32 (18.8)
11.087
0.001
Fits / Convulsion
68 (45.9)
80 (54.1)
122 (72.2)
47 (27.8)
22.630
0.000
Difficulty in breathing
86 (59.3)
59 (40.7)
134 (79.8)
34 (20.2)
15.587
0.000
105 (72.4)
40 (27.6)
155 (91.7)
14
(8.3)
20.419
0.000
Too weak to get out of bed
77 (52.4)
70 (47.6)
130 (76.5)
40 (23.5)
20.189
0.000
Water breaking
86 (58.1)
62 (41.9)
139 (82.2)
30 (17.8)
22.322
0.000
Abdominal pain
112 (75.7)
36 (24.3)
154 (90.6)
16
12.863
0.000
Fever
(9.4)
Table 3. Impressions of pregnant women on caring behaviors of nurses at baseline and endline Baseline
Endline
(n = 148)
(n = 170)
M [SD]
M [SD]
26.17 [11.19]
Kind (1-5)
t-test
p-value
27.63 [6.81]
4.299
0.000
4.36 [0.73]
4.59 [0.42]
2.730
0.007
Respectful (1-5)
4.38 [0.59]
4.66 [0.24]
3.781
0.000
Reliable (1-5)
4.33 [0.51]
4.64 [0.33]
4.278
0.000
Careful (1-5)
4.38 [0.59]
4.66 [0.31]
3.648
0.000
Understanding (1-5)
4.40 [0.49]
4.62 [0.32]
2.997
0.003
Warm (1-5)
4.24 [1.20]
4.48 [0.50]
2.274
0.024
Impression on caring behavior of nurses (6-30)
Conflict of interest: The authors declare that there are no conflicts of interest associated with this study.
Funding Source: Japan Society for the Promotion of Science (JSPS) Core-to-core program, Asia-Africa Science Platforms (2015-2018)
Ethical consideration: The study was conducted based on the principles of ethics, namely, harmlessness, voluntarily participation, anonymity, and protection of privacy and personal information. Ethical approval was obtained from the Tanzania National Institute for Medical Research 43
(NIMR) (Ref. NIMR/HQ/R.8c/Vol. IX/1604) and the Tanzania Commission for Science and Technology (COSTECH) (No. 2015-127-EF-2013-101). Ethical permission was also obtained from the Ethics Committee of St. Luke’s International University, Japan (Approval number: 15 - 007).
Acknowledgements: We thank all participants who shared their valuable time for this project. We are indebted to Dr. Edward F. Barroga (http://orcid.org/0000-0002-8920-2607; Academic Advisor/Mentor, Academic Writing Desk, St. Luke’s International University; Associate Professor and Senior Medical Editor, Tokyo Medical University), for his editorial review and helpful advice regarding our manuscript.
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