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Background: Early Initiation of antenatal care (ANC) and at least four visits during pregnancy allow screening and support for a healthy lifestyle and self-care during pregnancy however, community-directed interventions to improve access to these services are rarely explored. Objective: To assess the effect of community health worker (CHW) involvement on utilisation of antenatal services during pregnancy in resource-constrained rural settings in Uganda. Methods: We conducted a quasi-experimental evaluation study among mothers from Eastern Uganda. We used Difference in Differences (DiD) analysis to assess the effect of CHW intervention on ANC attendance. Components of the intervention included community dialogues and empowering CHWs to educate pregnant women about using maternal health services. The primary endpoints were early initiation of ANC and completion of at least 4 ANC visits. Results: Overall, the intervention significantly improved attendance of ≥ 4 ANC visits (DiD = 5.5%). The increase was significant in both intervention and comparison areas (46.2–64.4% vs. 54.1–66.8%, respectively), with slightly greater gains in the intervention area. Other elements that predicted ≥4 ANC attendance besides the intervention were post-primary education (PR1.14, 95%CI 1.02–1.30), higher wealth quintile (PR1.17, 95%CI 1.06–1.30), and early initiation of ANC (PR1.58, 95%CI 1.49–1.68). The intervention did not significantly improve early initiation of ANC (DiD =-1.3%). Instead, early initiation of ANC was associated with higher husband education (PR1.19,95%CI 1.02–1.39), larger household size (PR = 0.81, 95%CI 0.70–0.95), and higher wealth index (PR1.19,95%CI 1.03–1.37). Conclusions: The CHW intervention improved attendance of at least 4 ANC visits but not early initiation of ANC. There is need to promote CHW-led health education to increase attendance at 4+ ANC visits, but other approaches to promote early initiation are urgently required.
This household study was conducted in three districts in the South-Eastern part of Uganda (Busoga region). Buyende and Luuka were among the intervention districts, whereas Iganga served as the control district. Busoga region has about 3 million people, or 10% of Uganda’s population, covering an area of about 7100 sq. miles [3]. The region has ten administrative districts. Iganga District is also home to the Iganga/Mayuge Health Demographic Surveillance Site (HDSS), thus providing an opportunity for ongoing tracking of coverage, equity, and trends of key indicators. The HDSS area is predominantly rural but partly peri-urban in some trading areas. The three districts where the study was conducted have an estimated population of 1,100,000 people [15] and have similar rates of maternal and health services utilisation indicators. This study employed a quasi-experimental, non-equivalent group, pre-test–post-test design. We chose a quasi-experimental design since RCT would be impractical due to the group nature of the intervention. In contrast to RCTs, which take place in highly controlled settings, quasi-experimental design also offers practical options for conducting impact evaluations in real-world settings. The results of this design may be highly relevant for guiding policy. We conducted two cross-sectional surveys (baseline and follow up). We assessed the same outcomes at baseline and endline. The study units were households. Women who were pregnant within the previous year and lived in the study area, regardless of whether the baby was born preterm or full-term, and irrespective of the birth outcome, made up the study population (whether the baby was alive or dead). Women with severe illness or who had not lived in the community for at least one year were excluded. A baseline sample of 1,582 postpartum women in the intervention area and 388 women from the control areas were interviewed. During the endline evaluation, we interviewed a similar sample size of 1,661 and 401 mothers from intervention areas and control areas. Regarding sampling, 16 sub-counties were randomly selected (6 in each intervention district and 4 in the control district) by writing the names of all sub-counties on small pieces of paper, then picking one paper at a time without replacement until all sub-counties were obtained. We randomly selected one parish within each sub-county, and two villages were chosen randomly from each parish. With the help of local leaders, we compiled a list of all mothers who had given birth within the previous 12 months of the surveys. The respondents were sampled at the village level using simple random sampling from a village listing created with the assistance of the local council 1 (village) leader. Enumerators visited at least 50 households in the selected/sampled village, selecting one eligible respondent per eligible household. The same villages were considered in the 2015 endline evaluation. A similar approach was used to determine a cross-sectional sample of mothers who gave birth in 2014 for the endline survey. Complex interventions, such as the CHW program, require a convincing theory of change. This theory should be supported by a well-described hypothesis of intervention-to-outcome pathways [16]. The theory of change adopted for this study has been described in an earlier publication [11]. In brief, we expected the home visits made by CHWs and community dialogues to empower pregnant women to encourage ANC uptake, particularly through early initiation and completion of at least four ANC visits at the healthcare facility. CHWs would accomplish this through activities such as (i) counselling, which raises awareness of ANC and can serve as a source of motivation, as previously demonstrated [17]; (ii) informing pregnant women of the location of the nearest healthcare facility that provides ANC; (iii) the visit itself serving as a reminder or ‘nudge’ to women who were already planning to attend ANC or deliver at a healthcare facility; and (iv) CHWs exerting a normative social influence on women through their visits and by emphasising the importance of ANC and other maternal health services. We hypothesised that these activities would lead to an improvement in the timeliness and frequency of ANC uptake when compared with standard care. Appointments were made with CHWs and local village council (LC) leaders of the selected villages before the data collection exercise. One CHW and a representative from the LC led the Research Assistants (RAs) to the households that had been chosen. Data were collected from the mothers in selected homes through face-to-face interviews using a structured questionnaire developed based on reviewed literature on antenatal care attendance and community-based approaches [18–21]. The same questionnaire was used for both the baseline and follow-up studies. Since the baseline and endline were independent cross-sectional surveys, participants in the post-intervention survey included both new and baseline survey participants. Data on sociodemographic characteristics (age, parity, household size, highest education level, wealth index, occupation, and marital status) and maternal and child health service utilisation (ANC attendance and health facility deliveries) were collected. The questionnaires were filled out by experienced research assistants (RAs) who were well trained in objective interviewing. After completing the interviews, each RA compiled their completed questionnaires and turned them over to supervisors, who reviewed the tools, checked for errors, and completed the compilation. Before the baseline and endline surveys, research assistants were trained. The questionnaire and consent forms were available both in English and the local language (Lusoga), with the latter being the primary language used in data collection. Tools were pre-tested in five villages of Namungalwe sub-county in order to fine-tune the questionnaires to meet the required objectives set for evaluation. These villages had similar characteristics to study area settings but were not included in the final data collection. Questionnaires containing information from every participant in the study were kept securely, and only the study team had access to them. Data entry was performed by independent, experienced data entry clerks who had received two days of training. We kept all files on password-protected computers. Continuous variables such as age were summarised as mean and standard deviation and compared between baseline and endline using two-sample t-tests. Categorical data, on the other hand, were expressed as frequencies and proportions and compared between baseline and endline using Pearson’s chi-squared tests. To explore the contribution of the intervention package to early initiation of ANC and completion of at least four ANC visits, a modified Poisson regression incorporating the difference in differences (DiD) analyses (Equation (1)) with a less strict exchangeability assumption was used. The data were entered into Epi info 7 and then transferred for analysis into Stata 16.0 (StataCorp, College Station, Texas, USA). yit=β0+β1PT+β2Ti +β3(Pt*Ti) +μit (1) where yit is the outcome of interest, P is a dummy variable during the time period ‘t’, and T is a dummy variable for the treatment group. The interaction term, P × T, is equivalent to a dummy variable equal to 1 for observations in the treatment group in the second period. β3 is the DiD estimator, indicating whether the expected mean change in outcomes before and after the intervention differed between the intervention and control groups. We ran separate models for each study outcome. Multivariable modified Poisson regression was performed to understand the predictors of the study outcomes (early ANC initiation, optimal ANC attendance) after adjusting for known confounders such as age and level of education. Variables with p values ≤0.25 at the univariate level were known confounders, and variables we judged biologically plausible were considered for multivariate analysis. Hosmer – Lemeshow was used to assess the model’s goodness of fit [22]. We obtained formal approval from Makerere University School of Public Health Higher Degrees, Research and Ethics Committee (HDREC), the Uganda National Council for Science and Technology (UNCST) and the WHO Ethical Review Committee. Additionally, the study was approved by the district health teams and by the local authorities where the study was conducted. Before participating in the study, participants (adults and emancipated minors) provided written informed consent. The research assistants read an informed consent document to participants (in either English or the local language). All research procedures were conducted following the principles of the Helsinki Declaration, and all the activities followed standard operating procedures and codes of conduct.
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