- Email: [email protected]
From patient to client
Patient Education and Counseling 81 (2010) 442–447
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
From patient to client Olga de Haan * Netherland School Public and Occupational Health, Amsterdam, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 March 2010 Received in revised form 29 September 2010 Accepted 30 September 2010
Objective: To gain insight in the knowledge, attitude and practices of users and providers of reproductive health services in rural areas of Kyrgyzstan and Tajikistan before and after interventions. Methods: KAP (Knowledge, Attitude, Practices) studies under 500 respondents. Results: Training that addressed the determinants of behavioural change contributed to the motivation under health care providers to improve performances. The simultaneously implemented education program for users of health services enhanced the preparedness for birth of pregnant women and their family members. Both interventions had positive effects on health outcomes. Conclusions: Behavioural change, from hierarchic and directive into client-centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers. A client-centred attitude of health care providers is the key condition for sustainable improvement of service delivery. Improving client–provider communication is a cost-effective way to enhance the quality of care in low resource settings, such as in Central Asia. Practice implications: The providers can be best trained in a practical setting, when trainees are enabled to practice with real patients, under guidance of a highly skilled professional. Psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Health psychology Informed choices
1. Introduction Reproductive health services in former Soviet Union countries are characterized by one remarkable phenomenon: the absence of clients. The hierarchical and control-based health system is built around the doctor. The concept of ‘clients’ does not exist and patients are of the lowest priority: they just have to obey. Women have little access to information to prepare them for birth and practices in maternities are over-medicalized and strip women from human dignity. In addition, seriously outmoded standards hamper the introduction of evidence-based practices. Misconceptions about pregnancy and childbirth are widespread and elevate fears and anxiety. Health services are characterized by a highly medicalized and invasive approach, focusing on an aggressive cure rather than care and prevention. Another shortcomings in service delivery in the post-Soviet countries is the lack of motivation among health providers to perform. Manifestations of poor worker motivation are in general: lack of courtesy to patients, absenteeism or failure to treat patients in a timely manner [1], exactly the behaviour often
* Correspondence address: Netherland School Public and Occupational Health, P.O. Box 2557, 1000 CN Amsterdam, The Netherlands. Tel.: +31 20 4097000; fax: +31 20 4097099. E-mail address: [email protected]. 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.09.028
observed in former Soviet Union countries. Combined with the social taboo on sex and zero awareness among providers of individual integrity or respect towards patients’ needs, the resulting reproductive health services infantilize patients through one-way doctor to patient channels of communication. In Central Asia, maternal mortality rivals those of some African regions, with a mortality ratio of 170 in Tajikistan and 116 in Kyrgyzstan, as estimated by WHO for the year 2005. In this region, the predominantly Muslim population averages 4–5 children per woman and less than 50% of the married women use any contraceptive method, including traditional methods as LAM or withdrawal. The bleak and outdated health facilities are equipped only with about 50% of the necessary equipment, and health providers are practicing outdated routine practices. This all is paired with high levels of fear amongst the female population, of gynaecologists in general and of the Rachmanovsky chair in particular: this chair symbolizes the dehumanization of women during delivery (Fig. 1). The Netherland School of Public and Occupational Health implemented during 2006–2009 a 4-year project in Tajikistan and Kyrgyzstan: Services to the People: let the mountain come to Mohammed. This project aimed to open the gate to high quality care for vulnerable rural women under the motto: if people do not go to the health services, then we bring the health services to them (Figs. 2 and 3).
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Fig. 1. Rachmanovsky chairs in Kyrgyzstan and in Tajikistan.
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Fig. 2. Parents School in Tajikistan, lesson on human reproduction.
This project addressed the client–doctor communication in two ways: (1) From doctor to patient: Providers are trained on issues ranging from clients’ rights and providers’ needs to effective communication to counselling skills including breaking bad news. The training’s objective is behavioural change towards clients: adopting a client-centred rather than patient’s dependency approach, and moving from paternalistic to trustful and symmetric relations. (2) From patient to doctor: As it is not possible to improve the quality of consultation without sufficient level of awareness among women, a network of ‘‘Parents Schools’’ have been established. These are low-profile training and resource centres
[()TD$FIG]
offering Preparing for Birth courses to future parents, free of charge for the poorest, with moderate fees for those who can afford to pay. For health workers, an appropriate level of autonomy is one of the motivational job properties, [2] and an appropriate level of autonomy for patients is needed to make informed choices on their health. Therefore, the main strategy for the project Services to the People is to empower both the clients and the health providers by enhancing their decision-making capacities, with an expected cascade of results: (1) Behavioural change of providers, as increasing the decisionmaking power on the work floor and having more related responsibilities are positively related to motivation and work satisfaction. (2) Educated and informed clients experience less fear before and during delivering, hence user satisfaction is enhanced. (3) The combination of (1) and (2) leads to improved health outcomes, e.g. decrease of complications during delivery and post-partum period, medicine use in perinatal services and maternal and infant mortality.
2. Methods The objectives of Services to the People were realized by two main interventions at pilot sites. The interventions were designed following a baseline study at the start of the project [3]. 2.1. The baseline research Fig. 3. Client-centred services practised: As mama is still in the operation theatre after the C-section, baby Sholpon is put on papa’s belly, for the so needed skin-toskin contact. October 2009, Karakol Maternity (Kyrgyzstan).
The Standard Tool Kit [4] developed by the Safe Motherhood Initiative, was adapted, translated, and used by local project
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partners in Kyrgyzstan and Tajikistan to assess the level of birth preparedness of women and the competencies of providers. For providers, the assessment included attitudes and communication skills, as well as the level of medical-technical competences. For the local population, including not only the women themselves, but also important individuals around them such as husbands or mothers-in-law, a KAP study examined reproductive health decision-making processes and the level of knowledge about potential problems before, during and after childbirth. The main findings of the baseline research for the population were, that reproductive health decisions belong to the household domain: the husband or the eldest woman in a household decide about timing and spacing of children and the place of the delivery (home or maternity). Further, knowledge about physiology and perinatal complications was very low in both countries. A few women spontaneously mentioned more than one of the danger signs, but not a single man in the Tajikistan and Kyrgyzstan studies spontaneously listed even one danger sign. Low level of awareness about danger signs during pregnancy, delivery and after birth was found not only among primaparae, but also among multiparae. Several different factors could explain this. First, medical providers lack reproductive health counselling skills and have no access to relevant up-to-date literature. Further, there are virtually no materials available on reproductive health in a language and format that ordinary people can understand. Related to this, another factor could be religious traditions within the family, including a prohibition to read anything besides the Koran. From the researcher’s notebook G., 25 y.o. living in the district ‘‘Ala-Too’’, migrant from the Batken region, has 5 children with delivery interval of 1,5-3 years. Current pregnancy is the sixth one, she is 8 months pregnant. She hasn’t answered any question about her own and child’s health. G.: «In our family we read only the Koran and we do not discuss any questions regarding family planning; all decisions are taken by my husband who does not permit me to perform an abortion or to take pills’’. For the providers the main findings of the baseline research were, that service providers did not see facilitating trustful interaction with their patients as part of their professional competencies. Scores on the communication competence were low: no one achieved a 90% score, the minimum score for being categorized as ‘competent’. Providers also scored poorly on the knowledge tests. No providers in either country met the criteria on all themes of the test, meaning that none of the providers met the standard professional level of medical-technical knowledge on pregnancy, delivery and the postpartum period, including infant care. This points to a poor quality of care, and in fact to a dangerous environment for mother and child. The main conclusion of the baseline study was that birth facilities in Central Asia are risky places to deliver, as providers lack professional competences, are indifferent and do not feel responsible for the health outcomes of their services. The lack of knowledge of providers, combined with lack of knowledge about reproductive issues among the population, results in a deadly cocktail of ignorance, contributing to high maternal and infant mortality. 2.2. The interventions Seen the gaps in knowledge and decision-making skills under both the providers and under the population, the project team decided to empower them simultaneously through an educational program.
A ‘Professional Attitude & Effective Communication’ training program was implemented at the Central Regional Hospitals in Tajikistan (Shahrinav region, 1700 deliveries annually) and Kyrgyzstan (Issyk Kul region, 2800 deliveries annually). A total of 60 providers per country participated, of which one-third work in primary healthcare as family doctors who cover reproductive health and antenatal care, and two-thirds work in local maternities. The various professional groups, including obstetricians/ gynaecologists, neonatologists, family doctors, midwives and nurses, were trained together to guarantee that all received the same message and would follow the same approach on the work floor. During a 10-day in-hospital training, including night shifts for participating in deliveries, new concepts such as evidence based medicine and change management were introduced and obsolete medical-technical competences updated. The core of the training was the Effective Perinatal Care training [5], previously implemented in the former Soviet region by various organizations such as UNFPA, Zdrav+ and others. However, because most of the trainees participated at least one time in an EPC-course offered by others, and because of the detected zero awareness on client-centred approaches among providers, the project introduced a drastic change of focus in the course, from medical-technical towards communication skills. The main goal of the course offered by the project was to reach an attitude shift: from hierarchic, directive and authoritarian to symmetrical, clientcentred and supportive doctor–patient relations. During the primary in-hospital training and six bi-annual refresher training sessions of 3 to 5 days, elements of six cumulative blocks were offered, depending of local circumstances and needs: 1. Basic communications skills – body language, listening, the art of asking the right questions, reflecting on facts and feelings, tuning-in with the client. 2. Clients’ rights and providers’ needs – basic reproductive and patients’ rights, such as the right on information, privacy and respect, combined with the needs that providers have in order to work as professionals, such as access to professional literature and support from management. 3. Values, attitudes and beliefs – how do the prejudices, values and beliefs of the provider influence client–doctor interaction? 4. Counselling – including how to talk about sex, contraceptives, abortion, and domestic violence; detailed information about breaking bad news and dealing with passive/aggressive clients and their families. 5. Relations on the working floor – giving and receiving feedback from colleagues and clients, and personal styles of coping with conflicts. 6. The need for change – during the training, providers become aware that they themselves are part of the chain of changes towards quality improvement. A SMART-action is developed to plan the most needed changes at the facility level. Parallel to the trainings, a network of Parents Schools has been established at pilot sites, to educate clients of health services about reproductive health issues. The name ‘school’ refers to the raison d’eˆtre rather than to a physical building, as the School can be anywhere: from a room at the maternity to the living room in one’s house. The rationale for establishing these Schools was that women themselves play a key role in their reproductive health and that basic knowledge is of uttermost importance for survival when care is practically absent. ‘Parents’ refer to the importance of partners, as in Central Asia it is not the woman but her family – her husband and mother-in-law – who make decisions about her reproduction, so they should be addressed too. During ten 1.5 hour sessions, pregnant women follow a course to prepare them for birth, which covers the following topics:
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1. Physiology – the body and human reproduction, pregnancy, contraception, birth spacing, nutrition and health, growth of the foetus. 2. Sexuality and emotion – changes during and after pregnancy, sexual relations, role of hormones and environment. 3. Delivery – physiological birth, what to expect at the maternity, different birth positions as alternative to the Rachmanovsky chair, the role of the midwife/ob-gyn and partner, excursion to the local maternity and introduction to future birth-attendants. 4. Pathology – danger signs during pregnancy and post-partum period for mother and newborn, referral. 5. Dealing with pain – relaxation and exercises to cope with contractions. 6. Post-partum period – basic baby care, role of partner, breastfeeding, coping with changes in daily life, resuming contraception.
The population’s knowledge on physiology and birth preparedness increased significantly. Job satisfaction among maternity staff increased from almost non-existent to high. In the baseline, client satisfaction was moderate, most likely because clients could not compare with high quality care. Client satisfaction with maternity services increased after interventions from moderate levels to high levels. In pilot hospitals services are more client-oriented than before. For example, knocking on the door when a delivery is going on is now the rule. This seems to be a minor detail but is, in fact, a great improvement, as it was formerly common practice that during a delivery somebody would occasionally come in (sometimes without even closing the door), which seriously offended the privacy of the women.
Women were attracted to the Schools by specially trained female volunteers from the community. These volunteers were recruited from local Women’s Councils (Zhensoviets), a remnant of the Soviet Union. Originally meant to commit women to the communist ideals, nowadays they function as a bridge between the local authorities and the rural population, with volunteers coming from respected families and possess social capital, so they can influence local decision-making. Volunteers were asked who would like to help with improving the maternal health within their communities; next they were trained in Safe Motherhood issues and basic communication skills. The 12–15 activists per site paid home visits to inform the pregnant woman and, most importantly, the mother-in-law, about the existence of the School and the life-saving effects of attending the course. During the course, instructors promoted the participation of partners, including husbands, female friends, and mothers (in-law, as a compromise). Instructors – who were not necessarily health care providers – were selected based on their open minded attitude and potential training capacities and trained during one 5-day intensive training and six 2-day refresher trainings by a master trainer from Kazakhstan. Under the project 12 instructors per country were trained, who give courses to groups of 10–15 people, including both pregnant women and their partners, with 2–3 parallel groups each month. Thus, more than a hundred couples are reached annually.
The interviews conducted with providers after the training interventions make it clear that the attitude of providers makes the difference between formal acceptance of evidence-based medicine and motivation to change, e.g. behavioural change from indifferent and rude to supportive interactions with clients. The determinants of behavioural change such as motivation, satisfaction and performance (including improved outcomes) are all aspects that were addressed during training. Self-efficacy, pride, managerial openness, job requirements and values all had tremendous effects on the motivational outcomes of providers. This suggests that significant improvements in motivation can be achieved without offering financial incentives. Interviewed providers (n = 15 per site, 60 in total) all reported that they liked their job much better after the interventions (training). This despite the fact that at the start of the Communication training providers were reluctant to learn, stating that they had no time for extensive talks with their patients and, moreover, trustful relations belong to friendship and not to their professional domain. This resistance was taken away once providers practiced the communication and counselling skills, first during role-plays and later during the course in vis-a`-vis situations with their patients. ‘Our work has become easier, in the beginning we thought having all these partners around was a nuisance, but now we see that they really help us!’ is a quote that interviewers often noted. Providers, especially the ob-gyns, who were not trained, were resisting the new approaches in their facility. The management turned out to be an important factor in addressing the frictions effectively, by maintaining a supportive environment and by sending them for re-training whenever possible. Also, the practices of the trainees contributed to the maintenance of the clientcentred services; apparently they served as examples for the others. Quote from Nazeera K, 50 years, ob-gyn at Karakol Hospital:
3. Results After three years of implementation, the baseline research was repeated, this time with the addition of semi-structured interviews with providers on their assessment of the project results and client exit interviews after delivery with participants of the Preparing for Birth courses. Preliminary results are [6]: At pilot hospitals deliveries with the partner present increased in Kyrgyzstan from 10% to 70%, in Tajikistan, from 0% to 60%. New job descriptions were partly implemented at pilot hospitals for midwives, gynaecologists and neonatologist, aiming to enhance continuity of care. The occurrence of harmful routine practices decreased 90%, as evidence-based protocols were implemented. Complications in delivery, including caesareans, decreased 30%. The use of painkillers and other drugs decreased 40%. Maternal and newborn mortality decreased, though exact figures are not available yet. Professionals’ knowledge about physiology and complications management improved for the perinatal issues. However, even after the training, none of the providers were able to meet the international standards for professional competences.
‘‘I noticed there was no screaming in their delivery rooms, everything was so silent as if nothing was happening there! Also, they all got bunches of roses afterwards, much more than I. I myself began feeling a little like a stranger in this hospital, so I try to adapt and to be less impatient.’’ The main reasons mentioned by providers for the increased job satisfaction were that they were enabled by the management to make decisions as professionals (rather than just executing prescribed tasks), they were able to communicate effectively with their clients (informing and supporting) and most of all they took pride in the improved health outcomes. The interviews with providers were conducted two years after major interventions, suggesting that the changes are sustainable, as their attitude had been changed. Of the women who completed and passed the sessions at the Parents Schools, 80% delivered with a partner: in Kyrgyzstan
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mostly their husband, in Tajikistan mostly their mother(in-law). They all (n = 40 per site) reported that the interventions made their delivery much easier, even when there were complications, as they understood what was going on and not to panic. Women who had one or more births before the intervention all reported that the intervention made a difference between hell and heaven, thanks to enhanced knowledge, practical skills for coping with pain, trust in the (trained!) provider, freedom to choose a delivery position (not necessarily in the Rachmanovsky chair as before) and the support of the partner. Women also reported that they felt empowered to make their own decisions and that they felt better equipped to talk about contraception and sexual wishes with their husbands. Husbands, in their turn, reported that participating in the delivery led to a dramatic shift in their attitude towards their wives: they were impressed and proud, more respectful, more committed to the family, and more open to discuss sex and contraception. From the impact-research interviewer’s notebook: Sholpon A., 24, housewife, 3rd delivery in restructured maternity in Karakol, Kyrgyzstan:
You know, immediately after the birth I took my cell phone and called all my friends, telling them that they should deliver at this maternity: the people are so nice! Nothing to be afraid of: no shouting, no scolding, no things done to you that you do not understand. What a difference, I did not know that a delivery could be like this. 4. Discussion and conclusion 4.1. Discussion The main findings, that in post soviet practices (i) the providerclient communication is the crux of quality improvement in perinatal health services and (ii) that the attitude of providers is the discriminating factor between formal acceptance of changes and the motivation to change practices at the work floor, suggest that changes in service delivery are sustainable once the attitude of providers has been changed. Attitude change is more likely to occur when the trainees are emotionally touched, since only then they will internalize the values that underlay the rights-based and client-centred approaches. Health providers welcomed the patient-education part of the project, but especially the ob-gyns were reluctant to change their own practices, as if they were afraid of losing their authority. Moreover, they located the reasons for the poor service delivery outside themselves. Although often confronting, exploring the values, attitudes and beliefs of the health providers during training, and analysing the (negative) emotions that may occur during patient–doctor communication, seem to be effective to overcome this resistance. The training set-up, with trainees practicing on-the-spot counselling and deliveries under guidance of a highly qualified (in this project: Dutch) midwife, seems to be an effective way to enhance the awareness under providers that old practices should be changed and moreover: that they should change themselves. This was reached by addressing the determinants for health worker motivation such as selfefficacy and autonomy. Part and parcel of the project was to create a supportive environment, needed to enable the providers to act accordingly. The facility management is crucial for implementing such an enabling environment, as is a critical mass of motivated providers. This study indicates that the whole health system benefits from client-centred approaches: apart from the enhanced satisfaction at client and provider levels, at the facility level better health outcomes are reached with the same number of staff members and less medicine use is needed. Organizations and donors who aim to improve health systems in Central Asia could
benefit from the findings of this case study. All too often it is reported that once the international trainers and M&E experts leave the facility, all returns to normal, with obsolete routine practices re-emerging and donated equipment stored somewhere without being used. Focusing more on the behavioural change of providers and empowering the clients of the services, will make these efforts more effective. The findings are also relevant to other countries of the former Soviet Union, as all over the region the same hierarchical patient–doctor relation still dominates. Finally, this approach is also likely to be effective in other low-resource settings, such as in Sub-Sahara Africa and Asia. As the target samples in this case study were relatively small, big enough to indicate trends but not meant to enable elaborate statistical analyses, it would interesting to rehearse it with a bigger sample, and in other low-resource or post-soviet countries. 4.2. Conclusions This case-study is one of the first of its kind that explores the key determinants of motivation and decision-making under both providers and users of health facilities in transition countries and how these affect health outcomes. Based on the baseline and postintervention research, the following conclusions can be drawn: 1. An attitude shift, from hierarchic and directive into client– centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers and addressing the determinants for behavioural change. Managerial openness and job requirements were addressed during the project implementation at facility level through an open-door-policy (from ‘prison’ to community oriented) and a review of job descriptions to give more responsibilities and decision-making power to providers. Self-efficacy, pride, and values were addressed during the providers’ training. This had significant effects on other determinants for behavioural change, for instance, job satisfaction and the motivation to perform better. The level of the salary, which is often seen as a motivational driver, did not contribute to the attitude shift, as the (miserable) salaries were not raised during the project. 2. A client-centred attitude of health care providers is the key condition for sustainable improvement of mother & infant care in former Soviet countries such as Tajikistan and Kyrgyzstan. The client-centred attitude can be seen as key because it is the area in which the most marked improvement occurred, and was commonly remarked upon by both providers and clients. Other key conditions for quality care that were addressed by the project – the medical-technical knowledge and skills of providers, or the equipment and resources at facility level – did improve, but not significantly. The competences of the providers improved when compared to the baseline study, but nevertheless none of the tested providers met all of the professional standard indicators for level of medical-technical knowledge on pregnancy, delivery and the postpartum period. At the facility level, drastic improvements were implemented in terms of medicine supply, equipment and technical infrastructure, but nevertheless pilot maternities still did not meet all indicators for quality service. Despite the persistence of these shortcomings, the health outcomes (less complications during delivery and post-partum period, less medicine used and reduced maternal and newborn mortality) at the pilot services were significantly improved after the interventions. This can most likely be attributed to the changed role of the providers. 3. Improving client–provider communication is an effective way to enhance the quality of care in low resource settings, such as in Central Asia.
O. de Haan / Patient Education and Counseling 81 (2010) 442–447
The reasoning above also applies for this conclusion: no significant improvements occurred in key conditions for quality care, except for a radical shift in client–provider relations: from an authoritarian one-way communication that infantilizes the patients to a supportive and client–centred approach. This is due largely, but not only, to the attitude shift of the providers. The client education program as offered by the Parents School also contributed to this effect: knowledge on physiology, danger signs and birth preparedness increased significantly among women and their families. Providers treat women with more respect, clients are supported to deliver under their own conditions (free positions as alternatives for the Rachmanovsky chair, partner participation) and they are enabled to make an informed choice on family planning after delivery.
4.3. Practice implications The providers can be best trained in a practical setting, when trainees are enabled to practice immediately what they have learned with real patients, under guidance of a highly skilled professional. This would contribute to effective feedback. Also psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules for upgrading the knowledge and skills of providers. Training in this sense goes beyond the transfer of mere skills, as it enhances the awareness of the providers that they should change their attitude towards their clients. Disclosure statement No any actual or potential conflict of interest exists, including any financial, personal or other relationships with other people or
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organizations within three (3) years of beginning the work submitted that could inappropriately influence (bias) my work. Role of funding The project Services to the people is financed by Dutch Ministry of Foreign Affairs, Department Development Cooperation, TMF facility, with co-financing for restructuring hospitals and equipment by UNFPA, UNICEF and local administration. Acknowledgements Reproductive Health Alliance Kyrgyzstan, especially Galina Chirkina, Tatyana Popovitskaya and Arsen Askerov and Tajik Family Planning Alliance, especially Mohsharif Nasrulloeva and Dilafruz Shafivora, for implementing project activities, collecting and interpretation of data, Kristina Ferris for providing language help. References [1] Van Lerberghe W, Conceicao C, Van Damme W, Ferrinho P. When staff is underpaid: dealing with the individual coping strategies of health personnel. Bull WHO 2002;80:581–4. [2] Franco LM, Bennett S, Kanfer R, Stubblebine P. Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia. Soc Sci Med 2004;58:343–55. [3] Wiegers T, Boerma W, De Haan O. Safe motherhood, preparedness for birth in rural Kyrgyzstan and Tajikistan; 2006, Full report available at http://www.nivel. nl/ or at http://www.nspoh.nl/page.ocl?pageID=99&mode=&version=& MenuID=44. [4] The original Standard Toolkit has been published at Johns Hopkins University (JHPIEGO). Available at http://www.jhpiego.org/resources/pubs/mnh/ BPCRtoolkit.pdf. [5] http://www.euro.who.int/en/what-we-do/health-topics/Life-stages/maternaland-newborn-health/policy/effective-perinatal-care-training-package-epc. [6] Final results will be available in October 2010 at www.nspoh.nl and www. rhak.kg.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
From patient to client Olga de Haan * Netherland School Public and Occupational Health, Amsterdam, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 March 2010 Received in revised form 29 September 2010 Accepted 30 September 2010
Objective: To gain insight in the knowledge, attitude and practices of users and providers of reproductive health services in rural areas of Kyrgyzstan and Tajikistan before and after interventions. Methods: KAP (Knowledge, Attitude, Practices) studies under 500 respondents. Results: Training that addressed the determinants of behavioural change contributed to the motivation under health care providers to improve performances. The simultaneously implemented education program for users of health services enhanced the preparedness for birth of pregnant women and their family members. Both interventions had positive effects on health outcomes. Conclusions: Behavioural change, from hierarchic and directive into client-centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers. A client-centred attitude of health care providers is the key condition for sustainable improvement of service delivery. Improving client–provider communication is a cost-effective way to enhance the quality of care in low resource settings, such as in Central Asia. Practice implications: The providers can be best trained in a practical setting, when trainees are enabled to practice with real patients, under guidance of a highly skilled professional. Psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Health psychology Informed choices
1. Introduction Reproductive health services in former Soviet Union countries are characterized by one remarkable phenomenon: the absence of clients. The hierarchical and control-based health system is built around the doctor. The concept of ‘clients’ does not exist and patients are of the lowest priority: they just have to obey. Women have little access to information to prepare them for birth and practices in maternities are over-medicalized and strip women from human dignity. In addition, seriously outmoded standards hamper the introduction of evidence-based practices. Misconceptions about pregnancy and childbirth are widespread and elevate fears and anxiety. Health services are characterized by a highly medicalized and invasive approach, focusing on an aggressive cure rather than care and prevention. Another shortcomings in service delivery in the post-Soviet countries is the lack of motivation among health providers to perform. Manifestations of poor worker motivation are in general: lack of courtesy to patients, absenteeism or failure to treat patients in a timely manner [1], exactly the behaviour often
* Correspondence address: Netherland School Public and Occupational Health, P.O. Box 2557, 1000 CN Amsterdam, The Netherlands. Tel.: +31 20 4097000; fax: +31 20 4097099. E-mail address: [email protected]. 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.09.028
observed in former Soviet Union countries. Combined with the social taboo on sex and zero awareness among providers of individual integrity or respect towards patients’ needs, the resulting reproductive health services infantilize patients through one-way doctor to patient channels of communication. In Central Asia, maternal mortality rivals those of some African regions, with a mortality ratio of 170 in Tajikistan and 116 in Kyrgyzstan, as estimated by WHO for the year 2005. In this region, the predominantly Muslim population averages 4–5 children per woman and less than 50% of the married women use any contraceptive method, including traditional methods as LAM or withdrawal. The bleak and outdated health facilities are equipped only with about 50% of the necessary equipment, and health providers are practicing outdated routine practices. This all is paired with high levels of fear amongst the female population, of gynaecologists in general and of the Rachmanovsky chair in particular: this chair symbolizes the dehumanization of women during delivery (Fig. 1). The Netherland School of Public and Occupational Health implemented during 2006–2009 a 4-year project in Tajikistan and Kyrgyzstan: Services to the People: let the mountain come to Mohammed. This project aimed to open the gate to high quality care for vulnerable rural women under the motto: if people do not go to the health services, then we bring the health services to them (Figs. 2 and 3).
[()TD$FIG]
O. de Haan / Patient Education and Counseling 81 (2010) 442–447
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Fig. 1. Rachmanovsky chairs in Kyrgyzstan and in Tajikistan.
[()TD$FIG]
Fig. 2. Parents School in Tajikistan, lesson on human reproduction.
This project addressed the client–doctor communication in two ways: (1) From doctor to patient: Providers are trained on issues ranging from clients’ rights and providers’ needs to effective communication to counselling skills including breaking bad news. The training’s objective is behavioural change towards clients: adopting a client-centred rather than patient’s dependency approach, and moving from paternalistic to trustful and symmetric relations. (2) From patient to doctor: As it is not possible to improve the quality of consultation without sufficient level of awareness among women, a network of ‘‘Parents Schools’’ have been established. These are low-profile training and resource centres
[()TD$FIG]
offering Preparing for Birth courses to future parents, free of charge for the poorest, with moderate fees for those who can afford to pay. For health workers, an appropriate level of autonomy is one of the motivational job properties, [2] and an appropriate level of autonomy for patients is needed to make informed choices on their health. Therefore, the main strategy for the project Services to the People is to empower both the clients and the health providers by enhancing their decision-making capacities, with an expected cascade of results: (1) Behavioural change of providers, as increasing the decisionmaking power on the work floor and having more related responsibilities are positively related to motivation and work satisfaction. (2) Educated and informed clients experience less fear before and during delivering, hence user satisfaction is enhanced. (3) The combination of (1) and (2) leads to improved health outcomes, e.g. decrease of complications during delivery and post-partum period, medicine use in perinatal services and maternal and infant mortality.
2. Methods The objectives of Services to the People were realized by two main interventions at pilot sites. The interventions were designed following a baseline study at the start of the project [3]. 2.1. The baseline research Fig. 3. Client-centred services practised: As mama is still in the operation theatre after the C-section, baby Sholpon is put on papa’s belly, for the so needed skin-toskin contact. October 2009, Karakol Maternity (Kyrgyzstan).
The Standard Tool Kit [4] developed by the Safe Motherhood Initiative, was adapted, translated, and used by local project
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partners in Kyrgyzstan and Tajikistan to assess the level of birth preparedness of women and the competencies of providers. For providers, the assessment included attitudes and communication skills, as well as the level of medical-technical competences. For the local population, including not only the women themselves, but also important individuals around them such as husbands or mothers-in-law, a KAP study examined reproductive health decision-making processes and the level of knowledge about potential problems before, during and after childbirth. The main findings of the baseline research for the population were, that reproductive health decisions belong to the household domain: the husband or the eldest woman in a household decide about timing and spacing of children and the place of the delivery (home or maternity). Further, knowledge about physiology and perinatal complications was very low in both countries. A few women spontaneously mentioned more than one of the danger signs, but not a single man in the Tajikistan and Kyrgyzstan studies spontaneously listed even one danger sign. Low level of awareness about danger signs during pregnancy, delivery and after birth was found not only among primaparae, but also among multiparae. Several different factors could explain this. First, medical providers lack reproductive health counselling skills and have no access to relevant up-to-date literature. Further, there are virtually no materials available on reproductive health in a language and format that ordinary people can understand. Related to this, another factor could be religious traditions within the family, including a prohibition to read anything besides the Koran. From the researcher’s notebook G., 25 y.o. living in the district ‘‘Ala-Too’’, migrant from the Batken region, has 5 children with delivery interval of 1,5-3 years. Current pregnancy is the sixth one, she is 8 months pregnant. She hasn’t answered any question about her own and child’s health. G.: «In our family we read only the Koran and we do not discuss any questions regarding family planning; all decisions are taken by my husband who does not permit me to perform an abortion or to take pills’’. For the providers the main findings of the baseline research were, that service providers did not see facilitating trustful interaction with their patients as part of their professional competencies. Scores on the communication competence were low: no one achieved a 90% score, the minimum score for being categorized as ‘competent’. Providers also scored poorly on the knowledge tests. No providers in either country met the criteria on all themes of the test, meaning that none of the providers met the standard professional level of medical-technical knowledge on pregnancy, delivery and the postpartum period, including infant care. This points to a poor quality of care, and in fact to a dangerous environment for mother and child. The main conclusion of the baseline study was that birth facilities in Central Asia are risky places to deliver, as providers lack professional competences, are indifferent and do not feel responsible for the health outcomes of their services. The lack of knowledge of providers, combined with lack of knowledge about reproductive issues among the population, results in a deadly cocktail of ignorance, contributing to high maternal and infant mortality. 2.2. The interventions Seen the gaps in knowledge and decision-making skills under both the providers and under the population, the project team decided to empower them simultaneously through an educational program.
A ‘Professional Attitude & Effective Communication’ training program was implemented at the Central Regional Hospitals in Tajikistan (Shahrinav region, 1700 deliveries annually) and Kyrgyzstan (Issyk Kul region, 2800 deliveries annually). A total of 60 providers per country participated, of which one-third work in primary healthcare as family doctors who cover reproductive health and antenatal care, and two-thirds work in local maternities. The various professional groups, including obstetricians/ gynaecologists, neonatologists, family doctors, midwives and nurses, were trained together to guarantee that all received the same message and would follow the same approach on the work floor. During a 10-day in-hospital training, including night shifts for participating in deliveries, new concepts such as evidence based medicine and change management were introduced and obsolete medical-technical competences updated. The core of the training was the Effective Perinatal Care training [5], previously implemented in the former Soviet region by various organizations such as UNFPA, Zdrav+ and others. However, because most of the trainees participated at least one time in an EPC-course offered by others, and because of the detected zero awareness on client-centred approaches among providers, the project introduced a drastic change of focus in the course, from medical-technical towards communication skills. The main goal of the course offered by the project was to reach an attitude shift: from hierarchic, directive and authoritarian to symmetrical, clientcentred and supportive doctor–patient relations. During the primary in-hospital training and six bi-annual refresher training sessions of 3 to 5 days, elements of six cumulative blocks were offered, depending of local circumstances and needs: 1. Basic communications skills – body language, listening, the art of asking the right questions, reflecting on facts and feelings, tuning-in with the client. 2. Clients’ rights and providers’ needs – basic reproductive and patients’ rights, such as the right on information, privacy and respect, combined with the needs that providers have in order to work as professionals, such as access to professional literature and support from management. 3. Values, attitudes and beliefs – how do the prejudices, values and beliefs of the provider influence client–doctor interaction? 4. Counselling – including how to talk about sex, contraceptives, abortion, and domestic violence; detailed information about breaking bad news and dealing with passive/aggressive clients and their families. 5. Relations on the working floor – giving and receiving feedback from colleagues and clients, and personal styles of coping with conflicts. 6. The need for change – during the training, providers become aware that they themselves are part of the chain of changes towards quality improvement. A SMART-action is developed to plan the most needed changes at the facility level. Parallel to the trainings, a network of Parents Schools has been established at pilot sites, to educate clients of health services about reproductive health issues. The name ‘school’ refers to the raison d’eˆtre rather than to a physical building, as the School can be anywhere: from a room at the maternity to the living room in one’s house. The rationale for establishing these Schools was that women themselves play a key role in their reproductive health and that basic knowledge is of uttermost importance for survival when care is practically absent. ‘Parents’ refer to the importance of partners, as in Central Asia it is not the woman but her family – her husband and mother-in-law – who make decisions about her reproduction, so they should be addressed too. During ten 1.5 hour sessions, pregnant women follow a course to prepare them for birth, which covers the following topics:
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1. Physiology – the body and human reproduction, pregnancy, contraception, birth spacing, nutrition and health, growth of the foetus. 2. Sexuality and emotion – changes during and after pregnancy, sexual relations, role of hormones and environment. 3. Delivery – physiological birth, what to expect at the maternity, different birth positions as alternative to the Rachmanovsky chair, the role of the midwife/ob-gyn and partner, excursion to the local maternity and introduction to future birth-attendants. 4. Pathology – danger signs during pregnancy and post-partum period for mother and newborn, referral. 5. Dealing with pain – relaxation and exercises to cope with contractions. 6. Post-partum period – basic baby care, role of partner, breastfeeding, coping with changes in daily life, resuming contraception.
The population’s knowledge on physiology and birth preparedness increased significantly. Job satisfaction among maternity staff increased from almost non-existent to high. In the baseline, client satisfaction was moderate, most likely because clients could not compare with high quality care. Client satisfaction with maternity services increased after interventions from moderate levels to high levels. In pilot hospitals services are more client-oriented than before. For example, knocking on the door when a delivery is going on is now the rule. This seems to be a minor detail but is, in fact, a great improvement, as it was formerly common practice that during a delivery somebody would occasionally come in (sometimes without even closing the door), which seriously offended the privacy of the women.
Women were attracted to the Schools by specially trained female volunteers from the community. These volunteers were recruited from local Women’s Councils (Zhensoviets), a remnant of the Soviet Union. Originally meant to commit women to the communist ideals, nowadays they function as a bridge between the local authorities and the rural population, with volunteers coming from respected families and possess social capital, so they can influence local decision-making. Volunteers were asked who would like to help with improving the maternal health within their communities; next they were trained in Safe Motherhood issues and basic communication skills. The 12–15 activists per site paid home visits to inform the pregnant woman and, most importantly, the mother-in-law, about the existence of the School and the life-saving effects of attending the course. During the course, instructors promoted the participation of partners, including husbands, female friends, and mothers (in-law, as a compromise). Instructors – who were not necessarily health care providers – were selected based on their open minded attitude and potential training capacities and trained during one 5-day intensive training and six 2-day refresher trainings by a master trainer from Kazakhstan. Under the project 12 instructors per country were trained, who give courses to groups of 10–15 people, including both pregnant women and their partners, with 2–3 parallel groups each month. Thus, more than a hundred couples are reached annually.
The interviews conducted with providers after the training interventions make it clear that the attitude of providers makes the difference between formal acceptance of evidence-based medicine and motivation to change, e.g. behavioural change from indifferent and rude to supportive interactions with clients. The determinants of behavioural change such as motivation, satisfaction and performance (including improved outcomes) are all aspects that were addressed during training. Self-efficacy, pride, managerial openness, job requirements and values all had tremendous effects on the motivational outcomes of providers. This suggests that significant improvements in motivation can be achieved without offering financial incentives. Interviewed providers (n = 15 per site, 60 in total) all reported that they liked their job much better after the interventions (training). This despite the fact that at the start of the Communication training providers were reluctant to learn, stating that they had no time for extensive talks with their patients and, moreover, trustful relations belong to friendship and not to their professional domain. This resistance was taken away once providers practiced the communication and counselling skills, first during role-plays and later during the course in vis-a`-vis situations with their patients. ‘Our work has become easier, in the beginning we thought having all these partners around was a nuisance, but now we see that they really help us!’ is a quote that interviewers often noted. Providers, especially the ob-gyns, who were not trained, were resisting the new approaches in their facility. The management turned out to be an important factor in addressing the frictions effectively, by maintaining a supportive environment and by sending them for re-training whenever possible. Also, the practices of the trainees contributed to the maintenance of the clientcentred services; apparently they served as examples for the others. Quote from Nazeera K, 50 years, ob-gyn at Karakol Hospital:
3. Results After three years of implementation, the baseline research was repeated, this time with the addition of semi-structured interviews with providers on their assessment of the project results and client exit interviews after delivery with participants of the Preparing for Birth courses. Preliminary results are [6]: At pilot hospitals deliveries with the partner present increased in Kyrgyzstan from 10% to 70%, in Tajikistan, from 0% to 60%. New job descriptions were partly implemented at pilot hospitals for midwives, gynaecologists and neonatologist, aiming to enhance continuity of care. The occurrence of harmful routine practices decreased 90%, as evidence-based protocols were implemented. Complications in delivery, including caesareans, decreased 30%. The use of painkillers and other drugs decreased 40%. Maternal and newborn mortality decreased, though exact figures are not available yet. Professionals’ knowledge about physiology and complications management improved for the perinatal issues. However, even after the training, none of the providers were able to meet the international standards for professional competences.
‘‘I noticed there was no screaming in their delivery rooms, everything was so silent as if nothing was happening there! Also, they all got bunches of roses afterwards, much more than I. I myself began feeling a little like a stranger in this hospital, so I try to adapt and to be less impatient.’’ The main reasons mentioned by providers for the increased job satisfaction were that they were enabled by the management to make decisions as professionals (rather than just executing prescribed tasks), they were able to communicate effectively with their clients (informing and supporting) and most of all they took pride in the improved health outcomes. The interviews with providers were conducted two years after major interventions, suggesting that the changes are sustainable, as their attitude had been changed. Of the women who completed and passed the sessions at the Parents Schools, 80% delivered with a partner: in Kyrgyzstan
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mostly their husband, in Tajikistan mostly their mother(in-law). They all (n = 40 per site) reported that the interventions made their delivery much easier, even when there were complications, as they understood what was going on and not to panic. Women who had one or more births before the intervention all reported that the intervention made a difference between hell and heaven, thanks to enhanced knowledge, practical skills for coping with pain, trust in the (trained!) provider, freedom to choose a delivery position (not necessarily in the Rachmanovsky chair as before) and the support of the partner. Women also reported that they felt empowered to make their own decisions and that they felt better equipped to talk about contraception and sexual wishes with their husbands. Husbands, in their turn, reported that participating in the delivery led to a dramatic shift in their attitude towards their wives: they were impressed and proud, more respectful, more committed to the family, and more open to discuss sex and contraception. From the impact-research interviewer’s notebook: Sholpon A., 24, housewife, 3rd delivery in restructured maternity in Karakol, Kyrgyzstan:
You know, immediately after the birth I took my cell phone and called all my friends, telling them that they should deliver at this maternity: the people are so nice! Nothing to be afraid of: no shouting, no scolding, no things done to you that you do not understand. What a difference, I did not know that a delivery could be like this. 4. Discussion and conclusion 4.1. Discussion The main findings, that in post soviet practices (i) the providerclient communication is the crux of quality improvement in perinatal health services and (ii) that the attitude of providers is the discriminating factor between formal acceptance of changes and the motivation to change practices at the work floor, suggest that changes in service delivery are sustainable once the attitude of providers has been changed. Attitude change is more likely to occur when the trainees are emotionally touched, since only then they will internalize the values that underlay the rights-based and client-centred approaches. Health providers welcomed the patient-education part of the project, but especially the ob-gyns were reluctant to change their own practices, as if they were afraid of losing their authority. Moreover, they located the reasons for the poor service delivery outside themselves. Although often confronting, exploring the values, attitudes and beliefs of the health providers during training, and analysing the (negative) emotions that may occur during patient–doctor communication, seem to be effective to overcome this resistance. The training set-up, with trainees practicing on-the-spot counselling and deliveries under guidance of a highly qualified (in this project: Dutch) midwife, seems to be an effective way to enhance the awareness under providers that old practices should be changed and moreover: that they should change themselves. This was reached by addressing the determinants for health worker motivation such as selfefficacy and autonomy. Part and parcel of the project was to create a supportive environment, needed to enable the providers to act accordingly. The facility management is crucial for implementing such an enabling environment, as is a critical mass of motivated providers. This study indicates that the whole health system benefits from client-centred approaches: apart from the enhanced satisfaction at client and provider levels, at the facility level better health outcomes are reached with the same number of staff members and less medicine use is needed. Organizations and donors who aim to improve health systems in Central Asia could
benefit from the findings of this case study. All too often it is reported that once the international trainers and M&E experts leave the facility, all returns to normal, with obsolete routine practices re-emerging and donated equipment stored somewhere without being used. Focusing more on the behavioural change of providers and empowering the clients of the services, will make these efforts more effective. The findings are also relevant to other countries of the former Soviet Union, as all over the region the same hierarchical patient–doctor relation still dominates. Finally, this approach is also likely to be effective in other low-resource settings, such as in Sub-Sahara Africa and Asia. As the target samples in this case study were relatively small, big enough to indicate trends but not meant to enable elaborate statistical analyses, it would interesting to rehearse it with a bigger sample, and in other low-resource or post-soviet countries. 4.2. Conclusions This case-study is one of the first of its kind that explores the key determinants of motivation and decision-making under both providers and users of health facilities in transition countries and how these affect health outcomes. Based on the baseline and postintervention research, the following conclusions can be drawn: 1. An attitude shift, from hierarchic and directive into client– centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers and addressing the determinants for behavioural change. Managerial openness and job requirements were addressed during the project implementation at facility level through an open-door-policy (from ‘prison’ to community oriented) and a review of job descriptions to give more responsibilities and decision-making power to providers. Self-efficacy, pride, and values were addressed during the providers’ training. This had significant effects on other determinants for behavioural change, for instance, job satisfaction and the motivation to perform better. The level of the salary, which is often seen as a motivational driver, did not contribute to the attitude shift, as the (miserable) salaries were not raised during the project. 2. A client-centred attitude of health care providers is the key condition for sustainable improvement of mother & infant care in former Soviet countries such as Tajikistan and Kyrgyzstan. The client-centred attitude can be seen as key because it is the area in which the most marked improvement occurred, and was commonly remarked upon by both providers and clients. Other key conditions for quality care that were addressed by the project – the medical-technical knowledge and skills of providers, or the equipment and resources at facility level – did improve, but not significantly. The competences of the providers improved when compared to the baseline study, but nevertheless none of the tested providers met all of the professional standard indicators for level of medical-technical knowledge on pregnancy, delivery and the postpartum period. At the facility level, drastic improvements were implemented in terms of medicine supply, equipment and technical infrastructure, but nevertheless pilot maternities still did not meet all indicators for quality service. Despite the persistence of these shortcomings, the health outcomes (less complications during delivery and post-partum period, less medicine used and reduced maternal and newborn mortality) at the pilot services were significantly improved after the interventions. This can most likely be attributed to the changed role of the providers. 3. Improving client–provider communication is an effective way to enhance the quality of care in low resource settings, such as in Central Asia.
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The reasoning above also applies for this conclusion: no significant improvements occurred in key conditions for quality care, except for a radical shift in client–provider relations: from an authoritarian one-way communication that infantilizes the patients to a supportive and client–centred approach. This is due largely, but not only, to the attitude shift of the providers. The client education program as offered by the Parents School also contributed to this effect: knowledge on physiology, danger signs and birth preparedness increased significantly among women and their families. Providers treat women with more respect, clients are supported to deliver under their own conditions (free positions as alternatives for the Rachmanovsky chair, partner participation) and they are enabled to make an informed choice on family planning after delivery.
4.3. Practice implications The providers can be best trained in a practical setting, when trainees are enabled to practice immediately what they have learned with real patients, under guidance of a highly skilled professional. This would contribute to effective feedback. Also psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules for upgrading the knowledge and skills of providers. Training in this sense goes beyond the transfer of mere skills, as it enhances the awareness of the providers that they should change their attitude towards their clients. Disclosure statement No any actual or potential conflict of interest exists, including any financial, personal or other relationships with other people or
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organizations within three (3) years of beginning the work submitted that could inappropriately influence (bias) my work. Role of funding The project Services to the people is financed by Dutch Ministry of Foreign Affairs, Department Development Cooperation, TMF facility, with co-financing for restructuring hospitals and equipment by UNFPA, UNICEF and local administration. Acknowledgements Reproductive Health Alliance Kyrgyzstan, especially Galina Chirkina, Tatyana Popovitskaya and Arsen Askerov and Tajik Family Planning Alliance, especially Mohsharif Nasrulloeva and Dilafruz Shafivora, for implementing project activities, collecting and interpretation of data, Kristina Ferris for providing language help. References [1] Van Lerberghe W, Conceicao C, Van Damme W, Ferrinho P. When staff is underpaid: dealing with the individual coping strategies of health personnel. Bull WHO 2002;80:581–4. [2] Franco LM, Bennett S, Kanfer R, Stubblebine P. Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia. Soc Sci Med 2004;58:343–55. [3] Wiegers T, Boerma W, De Haan O. Safe motherhood, preparedness for birth in rural Kyrgyzstan and Tajikistan; 2006, Full report available at http://www.nivel. nl/ or at http://www.nspoh.nl/page.ocl?pageID=99&mode=&version=& MenuID=44. [4] The original Standard Toolkit has been published at Johns Hopkins University (JHPIEGO). Available at http://www.jhpiego.org/resources/pubs/mnh/ BPCRtoolkit.pdf. [5] http://www.euro.who.int/en/what-we-do/health-topics/Life-stages/maternaland-newborn-health/policy/effective-perinatal-care-training-package-epc. [6] Final results will be available in October 2010 at www.nspoh.nl and www. rhak.kg.