Background: This study set out to investigate how incentives for mothers, health workers and boda–boda riders can improve the community-based referral process and deliveries in the rural community of Busoga region in Uganda. Both the monetary and non-monetary incentives have been instrumental in the improvement of deliveries at health centres. Methods: The study was a 2 arm cluster non-randomized control trial study design; with intervention and control groups of mothers, health workers and boba–boda (commercial motor-cycle) riders from selected health centres and communities in Busoga region. Among the study interventions was the provision of incentives to mothers, health workers (midwives and VHTs) and boda–boda riders for a duration of 6 months. Monetary and non-monetary incentives were applied in this study, namely; provision of training, training allowances, refreshments during the training, payment of transport fares by mothers to boda–boda riders, free telephone calls through establishment of a pre-paid Closed Caller User Group (CUG) and provision of bonus airtime to all registered CUG participants and rewards to best performers. The study used a mixed methods design. Descriptive statistical analysis was computed using STATA version 14 for the quantitative data and thematic analysis for qualitative data. Results: Findings revealed that incentives improved community-based referrals and health facility deliveries in the rural community of Busoga. The proportion of mothers who delivered from health centres and used boda–boda transport were 70.5% in the intervention arm and only 51.2% in the control arm. Of the mothers who delivered from the health centres, majority (69.4%) were transported by trained boda–boda riders while only 30.6% were transported by un-trained boda–boda riders. And of the mothers transported by the boda boda riders, 21.3% in the intervention arm reported that the riders responded to their calls within 20 min, an improvement from 4.3% before the intervention. Mothers who were responded to between 21–30 min increased from 31.4% to 69.6% in the intervention arm while in the control arm, it only increased from 37.1% to a dismal 40.3%. Interestingly, as the time interval increased, the number of boda–boda riders who delayed to respond to mothers’ calls reduced. In the intervention arm, only 6.2% of the mothers stated that boda–boda riders took as many as 31–60 min’ time interval to respond to their calls in post intervention compared to a whopping 54.9% in the pre intervention time. There was little change in the control arm from 53.2% in the pre intervention to 41.2% in the post intervention. Conclusion: Incentives along the maternal health chain are key and the initiative of incentivising the categories of stakeholders (mothers, midwives, the VHTs and the boda–boda riders) has demonstrated that partnerships are very critical in achieving better maternal outcomes (health facility-based deliveries) as a result of proper referral processes.
The study was a 2 arm cluster non-randomized control trial study design; with an intervention group and a control group from selected health centres and communities. The study interventions involved providing incentives to mothers, health workers (midwives and VHTs) and boda–boda riders and this was done in a period of 6 months. The study was carried out in the rural districts of Busoga in Uganda. Local level participants came from the districts of Bugiri and Iganga where study projects were conducted in selected Sub-Counties that made up the intervention and control arms. These sub counties included; Nambale, Nabitende, Nawandala in Iganga district and Budaya Sub County in Bugiri district for the intervention arm while Nawaningi, Ibulanku and Makuutu in Iganga district and Nabukalu in Bugiri district formed the control arm. The intervention health facilities included; Bugono health centre IV, Kasambika health centre III, Nambale health centre III, Nawandala health centre III, and Namusiisi health centre III in Iganga district and Mayuge health centre III in Bugiri. While the control arm included; Makuutu health centre III, Bunyiiro health centre III, Busesa health centre IV in Iganga district and Nabukalu health centre III in Bugiri district. The reason for choice of study area was that motorcycle ambulances had once been operating under a funded project and had not been sustained. Therefore the study aimed at testing a local initiative that is more sustainable since it used locally available motorcycle (boda–boda) groups mobilised with the aim of referring mothers for further management at the different levels of health centres. The participants in Table Table11 were boda–boda riders, health workers (midwives and VHTs) and mothers. These were the primary target beneficiaries for the incentives and focus was based on these categories for this presentation in the intervention and control arms. Meanwhile, in the control arm, the study participants did not benefit from the incentives. Study participants in both intervention and control arms based on sub-counties The mothers were recruited from the antenatal register based on their willingness and meeting the inclusion criteria and in the selected study villages and sub counties. Mothers in their third trimester were recruited purposely to determine the impact of the incentives. Mothers were recruited in both the intervention and control arms. The boda–boda riders were recruited basing on their operating stage (work station), activeness and willingness to take part in the study and be trained. Boda–boda riders who were from boda–boda stations within the study sub counties who had no registered crime with police were selected. The midwives from the selected health facilities were recruited basing on their expressed interest and experience in research. They must have worked with the health facility for over 6 months. The VHTs were recruited purposively based on their presence in the selected sub counties together with their willingness to take part in the study. Also, very active VHTs were considered for this study. Consent was sought from all the participants (midwives, boda–boda riders, VHTs and mothers) before they were initiated into the study. For this study, purposive and random sampling techniques were employed. Study participants were identified from different data sources such as delivery register, ANC register and PNC registers in the selected health centres, VHTs registers at the district health office and boda–boda riders’ register at the village, sub county or district levels. Random methods were used to select from a given register to give each qualifying member a chance. One of the cross-cutting interventions was training. Four training sessions were conducted in the selected four sub counties for the intervention group for the boda–boda riders and health workers. The training lasted five days. Mothers on the other hand were trained from the health centres during the ANC visits. Participants in the training were facilitated and compensated for the days in training since some of the riders did not own motorcycles and were supposed to deposit their commissions to the motorcycle owners. Sessions were conducted for a relatively short period of time (9 am–2 pm) daily to allow the riders continue with their daily work after the training since there was demand for their services in the community. The VHTs and midwives were also facilitated with allowances in the training. Training sessions of mothers at health centres took a shorter time of around 1–2 h. These were mothers in their third trimester. As an incentive for the training, mothers were given only refreshments on every ANC visit. Another intervention was use of the closed caller user groups (CUG). Participants who benefited from this were the mothers, boda–boda riders, VHTs and midwives. Participants in the control arm did not benefit from the CUG. On consent, participants in the intervention arm were registered by the MTN telecommunication company to benefit from the free communication calls between all the members in the group. As another strategy, a bonus airtime of 10,000 Uganda shillings was given to each member of the group for communicating to other members who were not in the group during times of emergency. This was in a situation where the boda–boda rider was far and would use the bonus airtime to call another boda–boda rider at the stage to stand in for him regardless of whether he was in the CUG or not. In order for mothers to fully benefit from the boda–boda services, they were continuously encouraged to save money in the savings boxes for a sustainable motivation of boda–boda riders, as an intervention. This money was to pay for mothers’ transport fares for boda–boda services. It motivated the boda–boda riders because they were assured of their payments for the services. There was increased access and quality of health care services in local communities. The terms of payment for boda–boda transport services were mutually agreed upon between the mothers and the boda–boda riders in accordance with the distance travelled to reach the health facility. The study commenced with a baseline survey in both groups so as to get statistics for comparison after the intervention. This was important for determining the extent of the changes brought by the intervention. Questionnaires: We had baseline and exit interview questionnaires that were filled at the health facility for the mothers who used boda–boda transport in to the health centres. Interview guide: Data was also collected using the key informant and in-depth interview guides for the boda–boda riders, mothers, VHTs and midwives in selected health facilities of the intervention and control arms. Focus group discussions (FGDs): This was done at baseline as an entry point and later on when executing the study. It consisted of different stakeholders in the study. Document review checklist: this was designed to capture data from the secondary source. These included; delivery registers, ANC registers and PNC registers. Data analysis of descriptive statistics was computed using STATA version 14 for the quantitative data. Paired t-tests of independence were used to determine the statistical significance of the different variables with p-value set at 0.05 and confidence interval at 95%. In order for the study to be informative, difference-in-difference (DID) framework was used. The simplest form of the DID design is a special case in which there are only two groups observed in two time periods. DID was used to determine the change effect based on the average value and its statistical significance. Atlas Ti version 7 was used for qualitative analysis. It involved re-reading the interview transcripts to identify themes and sub themes that emerged from the respondents’ answers during the FGDs, Key Informant Interviews (KIIs) and In-depth Interviews (IDIs). The arrangement for analysis was based on the topics and questions formulated for the interviews in order to synthesize the answers to the proposed questions.
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