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

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Study Justification:
– The study evaluates the effectiveness of a cadre of maternal, newborn, and child health community health workers (MNCH CHWs) in Morogoro Region, Tanzania.
– It aims to identify the impact of various design elements on knowledge, time allocation, service delivery, satisfaction, and motivation of the MNCH CHWs.
– The study provides insights into the challenges faced by the program and suggests potential solutions for improvement.
Study Highlights:
– The study found that MNCH CHWs in Morogoro Region were more likely to be unmarried, younger, and more educated compared to earlier CHWs.
– The knowledge scores of MNCH CHWs were lower than those of health center providers but comparable to earlier CHWs.
– MNCH CHWs reported covering a mean of 186 households and provided MNCH services for 5 hours weekly.
– Attendance of monthly facility-based supervision meetings was nearly universal, but data quality assessments highlighted inconsistencies.
– Financial incentives and bicycles for transport, which were part of the program plans, were not received by a significant portion of CHWs.
Recommendations for Lay Reader and Policy Maker:
– The study suggests that a broader range of community members could be recruited as CHWs, as the social profile of CHWs did not significantly affect knowledge or service delivery.
– Time spent on service delivery by MNCH CHWs was limited, highlighting the need for increased resources and support.
– Simplification of service delivery registers is recommended to reduce inconsistencies, while also expanding the indicators to include timing of antenatal and postpartum visits.
Key Role Players:
– Ministry of Health, Social Welfare, and Jhpiego: Responsible for program implementation, training, and supervision of MNCH CHWs.
– Health center providers: Collaborate with MNCH CHWs and provide support and supervision.
– Research assistants: Conduct surveys and observations to collect data for evaluation.
Cost Items for Planning Recommendations:
– Recruitment and training of MNCH CHWs
– Financial incentives for CHWs
– Bicycles for transport
– Supervision and support for MNCH CHWs
– Improvement of service delivery registers
– Additional resources for increased service delivery
Please note that the cost items provided are general categories and not actual cost estimates.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a quantitative survey and data extracted from registers and observations. However, the abstract does not provide information on the sample size or the methodology used for data collection. To improve the evidence, the abstract should include details on the sample size, sampling method, and data collection procedures.

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.

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women and new mothers with information and reminders about antenatal and postpartum care, as well as access to teleconsultations with healthcare providers.

2. Community-Based Transportation: Implement a transportation system specifically designed to transport pregnant women to healthcare facilities for antenatal and postpartum visits. This could involve partnerships with local transportation providers or the use of community-owned vehicles.

3. Community Health Worker (CHW) Training and Support: Enhance the training and support provided to CHWs to improve their knowledge and skills in maternal health. This could include regular refresher trainings, mentoring programs, and access to updated educational materials.

4. Incentives for CHWs: Ensure that CHWs receive the financial incentives promised to them for their work in providing maternal health services. This could help motivate and retain CHWs, leading to improved access to care.

5. Strengthening Data Collection and Monitoring: Implement systems to improve the quality and consistency of data collected by CHWs, such as simplifying service delivery registers and providing regular supervision and feedback on data accuracy.

6. Community Engagement and Education: Conduct community awareness campaigns to educate community members about the importance of maternal health and encourage them to seek antenatal and postpartum care. This could involve community meetings, radio programs, and the use of local influencers.

7. Integration of Services: Integrate maternal health services with other healthcare services, such as family planning and child health, to provide comprehensive care to women and their families. This could improve efficiency and convenience for patients.

8. Strengthening Referral Systems: Develop and strengthen referral systems between CHWs, primary healthcare facilities, and higher-level healthcare facilities to ensure that pregnant women and new mothers receive appropriate care at the right level of the healthcare system.

9. Public-Private Partnerships: Foster partnerships between the public and private sectors to improve access to maternal health services. This could involve collaborations with private healthcare providers, pharmaceutical companies, and technology companies to leverage their resources and expertise.

10. Empowering Women and Girls: Address underlying social and cultural factors that hinder access to maternal health services, such as gender inequality and lack of education. This could involve initiatives to empower women and girls, such as providing scholarships for girls’ education and promoting women’s leadership in healthcare.
AI Innovations Description
The recommendation to improve access to maternal health based on the study findings is to address the following challenges:

1. Improve knowledge: The study found that the knowledge of maternal, newborn, and child health community health workers (MNCH CHWs) was low in several domains. To improve access to maternal health, it is important to provide comprehensive and ongoing training to MNCH CHWs to enhance their knowledge and skills in providing preventive and promotive services during the antenatal and postpartum periods.

2. Simplify service delivery registers: The study highlighted inconsistencies in the data quality of service delivery registers. Simplifying the registers and providing clear guidelines on how to accurately record information can help improve the quality and consistency of data. This will enable better monitoring and evaluation of MNCH services and identify areas for improvement.

3. Strengthen supervision and support: The study found that MNCH CHWs received monthly facility-based supervision meetings, but the focus was largely on registers. Supervision visits should be expanded to include mentoring and support in delivering MNCH services effectively. This will help address any challenges or gaps in knowledge and skills and provide motivation and guidance to MNCH CHWs.

4. Provide incentives: The study revealed that only 56% of MNCH CHWs had received financial incentives, despite program plans to provide them. Ensuring that MNCH CHWs receive the promised incentives, such as financial support and transportation, can help motivate them to continue providing services and improve access to maternal health.

5. Expand the cadre of CHWs: The study found that the social profile of CHWs was not significantly associated with knowledge or service delivery. This suggests that a broader range of community members could be recruited as CHWs to increase the coverage and access to maternal health services. This can be done by identifying and training individuals with secondary school education or higher, as well as those who may not have formal education but have the motivation and commitment to serve their communities.

By addressing these recommendations, the access to maternal health can be improved, leading to better health outcomes for mothers and newborns in Morogoro Region, Tanzania.
AI Innovations Methodology
Based on the provided description, here are two potential recommendations for improving access to maternal health:

1. Increase the number of trained maternal, newborn, and child health community health workers (MNCH CHWs) in Morogoro Region, Tanzania. This can be done by expanding the recruitment and training efforts to include a broader range of community members, not just those with secondary school education. By increasing the number of MNCH CHWs, more households can be covered and more pregnant and postpartum women can receive the necessary counseling and support.

2. Improve the quality of service delivery registers used by MNCH CHWs. Simplify the registers to reduce inconsistencies and ensure accurate recording of data. Additionally, expand the registers to include indicators on the timing of antenatal and postpartum visits. This will help monitor and evaluate the effectiveness of the MNCH CHW program and identify areas for improvement.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of pregnant and postpartum women receiving counseling, the number of antenatal and postpartum visits conducted, and the percentage of women seeking facility deliveries.

2. Collect baseline data: Gather data on the current status of these indicators before implementing the recommendations. This can be done through surveys, interviews, and data extraction from existing health information systems.

3. Implement the recommendations: Increase the number of trained MNCH CHWs and improve the quality of service delivery registers as per the recommendations.

4. Monitor and evaluate: Continuously collect data on the identified indicators after implementing the recommendations. This can be done through regular surveys, interviews, and monitoring of service delivery registers.

5. Analyze the data: Compare the baseline data with the post-implementation data to assess the impact of the recommendations. Calculate the changes in the indicators and determine if there has been an improvement in access to maternal health.

6. Interpret the results: Analyze the findings to understand the effectiveness of the recommendations. Identify any challenges or barriers that may have influenced the outcomes.

7. Adjust and refine: Based on the results, make any necessary adjustments or refinements to the recommendations. This could include further increasing the number of trained MNCH CHWs or implementing additional strategies to improve the quality of service delivery.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health in Morogoro Region, Tanzania.

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