Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania

Background: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation. Methods: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program’s start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs. Results: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles. Conclusions: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits. Two hundred kilometers west of Dar es Salaam, Morogoro Region is home to over 2.2 million people dispersed over 70 000 km2, making it the sixth most populous and second largest of the country’s 25 mainland regions [10]. Seventy-three percent of Morogoro Region is rural with regional averages for education, poverty, and care seeking similar to national averages [10]. Over half of the population (51%) falls within the middle to upper middle wealth quintiles, as compared to 42% on a national level [11]. In the health sector, trends in care seeking for critical MNCH services mirror national trends for postnatal care (35%) and are slightly higher than national averages for most other indicators, including antenatal care (ANC) utilization (98% versus 96%), facility deliveries (58% versus 50%), and skilled birth attendance (61% versus 51%) [11]. Implemented by the MoHSW with support from Jhpiego and established through the USAID-funded Mothers and Infants, Safe, Healthy and Alive (MAISHA) program, the Integrated Community to Facility MNCH Program aims to improve access to and quality of maternal, newborn, and reproductive health services. Integrated MNCH CHW Program training activities began in 2010 with a 6-day training of health center providers (mean of 2–4 per facility) according to facility-based guidelines (Table 1). In 2012, in districts where facility-based training occurred, 2 health centers and 10 dispensaries (5 dispensaries per health center) were selected as sites for the MNCH CHW program. For each health center or dispensary selected, two villages were identified and asked to nominate one male and one female resident with ideally secondary school education to serve as MNCH CHWs (Additional file 1: Figure S1). Selected CHWs received training for 21 days on behavior change, interpersonal communication and counseling, care during pregnancy, maternal postpartum care, newborn and child care, infant and young child feeding, community-based family planning, prevention of mother to child transmission, community involvement and participation, the integrated management cascade and supportive supervision, and monitoring and evaluation. Following training, CHWs were deployed to their home communities to conduct surveillance for pregnancy and delivery and provide counseling during three pregnancy and six postpartum home visits. Counseling was intended to elicit adoption of optimal health practices and promote the use of MNCH services among pregnant, postpartum women and their support networks (including partners and other members of the community). MNCH CHWs were supervised by trained facility-based dispensary and health center providers (enrolled nurses and/or clinical officers) through monthly supportive supervision visits and by MoHSW (regional and district) and Jhpiego staff on a quarterly basis. Supervision visits focused on a review of registers and reporting forms for data quality, activity planning, and a review of achievements and planning. Additional details on the content and effect of supervisory activities are presented elsewhere [12]. MNCH CHW program implementation strategy Table 2 summarizes data sources. The evaluation of MNCH CHWs sought to determine their profile and MNCH knowledge, CHW to population coverage ratio, program monitoring and supervision, incentives, satisfaction and motivation, and service delivery. Data sources for assessing outputs of MNCH CHW program activities in five districts of Morogoro, Tanzania To determine the MNCH CHW profile, knowledge, supervision, and service delivery outputs, a quantitative survey drawing from the MoHSW MNCH national guidelines on the content of training provided was administered to 228 (of the 238) MNCH CHWs following their recruitment, training, and deployment (Table 3). MNCH CHWs trained at least 3 months (from December 2012 to July 2013) prior to the start of the survey in October 2013 were eligible for inclusion. If participants were unavailable during researchers’ first visit to a village, a return visit for the interview was arranged at a later date during the period of data collection. Participants were not included if they did not consent to the interview, dropped out of the program, were traveling with an unknown return date, sick/hospitalized, or deceased at the time of data collection. The survey administered to consenting individuals included sections on CHW socio-demographics, service delivery, supervision, incentives, satisfaction, motivation, and MNCH knowledge. The latter included 38 questions with 191 possible responses (unprompted) across the following domains: pregnancy (3 questions), postpartum (3 questions), newborn care (3 questions), child health (7 questions), nutrition (4 questions), HIV transmission (3 questions), malaria (1 question), infection prevention (3 questions), injury prevention 1 (question), and family planning (10 questions), all of which aligned with the CHW curriculum. The average number of correct responses was used to generate a composite score for each domain and an overall average derived from across the averages calculated for each of the 10 domains (mean of means). MNCH CHW profile and characteristics MNCH CHW knowledge results were compared against knowledge surveys administered to two populations of providers operating in the same geographic area: (1) health center reproductive child health (RCH) providers (n = 88) and (2) CHWs identified in the same districts prior to the program’s start at the community level (n = 53). These comparisons were intended to spur discourse on MNCH CHW eligibility criteria and provide broader insights into MNCH CHW competency and service delivery. RCH providers in nine health centers (n = 88) were interviewed during a facility assessment survey conducted in 2012. In 2011, prior to the rollout of MNCH CHWs, a CHW census was carried out to determine the number of providers and assess knowledge and service delivery of individuals who self reported and/or were said to be CHWs (n = 53) by key stakeholders including village leaders and facility-based providers. Once identified, research assistants administered a quantitative survey exploring personal characteristics, working conditions, incentives, knowledge, motivation, and job satisfaction. Service delivery outputs were measured by extracting data from the Health and Management Information System (HMIS) registers of interviewed MNCH CHWs for the 5 months preceding the survey (May to September 2013) and through direct observations. For the latter, a time motion study was conducted from December 2013 to January 2014 among a sub-sample of ~15% (n = 33) of MNCH CHWs randomly selected from among those interviewed for the quantitative survey. Observations sought to improve understanding of the frequency and content of MNCH service provision, including use of job aidsa, as well as the broader context within which services are provided. The time motion study was constrained to the CHW’s village of residence and spanned for a period of up to six consecutive days beginning on a Wednesday and ending on a Monday in most instances. During the period of observation, a team of independent research assistants observed and continuously timed all activities carried out between the hours of 8 am and 5 pm. Activities performed outside of the observation window (from 5 pm to 8 am) were self-quantified at the start of each new day and recorded as “reported time allocation.” Findings are presented only on observed time allocation. To assess the quality of HMIS registers, among the MNCH CHWs observed during the time motion study (n = 33), we compared MNCH monthly summary sheets for 3 months with the maternal and child health (MCH) registers for the same 3 months for each of the 33 CHWs. Summary sheets form the basis of reported service delivery statistics and are submitted by individual MNCH CHWs to supervisors monthly and ultimately aggregated across all MNCH CHWs. The MNCH CHW summary sheets were assessed for discrepancies (over or under reporting) with the MCH registers in the number of the following visits: new pregnant women, returning pregnant women, neonates, children 1–12 months old, children 12–59 months old, and total home visits. For each type of visit, we calculated the number of CHWs with discrepancies and the magnitude of these discrepancies. We also assessed for patterns of discrepancies by CHW gender, education, and date of training. Quantitative data were double entered and cleaned using Epi Info software, with statistical analyses performed using Stata 12.0. Summary composite scores for knowledge were calculated by taking the average number of correct responses for each domain and then an overall average across the averages calculated for each of the 10 domains (mean of means). Ordered logistic regression models were used to explore associations between MNCH CHW characteristics (gender, age, education, assets, date of training) and composite knowledge scores overall and across domains. An asset index was constructed from CHW household assets and characteristics, using principal components analysis. Time motion data were analyzed using basic frequencies and cross tabulations. The study received ethical approval from the Muhimbili University of Health and Allied Sciences and Johns Hopkins School of Public Health Institutional Review Boards. Preliminary findings were shared with key decision makers in Tanzania from the MoHSW and Jhpiego for their feedback and review prior to publications being drafted.