The impact of community based continuous training project on improving couples’ knowledge on birth preparedness and complication readiness in rural setting Tanzania; A controlled quasi-experimental study

Background It is widely accepted that community-based interventions are vital strategies towards reduction of maternal and neonatal mortalities in developing counties. This study aimed at finding the impact a Community Based Continuous Training (CBCT) project in improving couples’ knowledge on birth preparedness and complication readiness in rural Tanzania. Method The quasi-experimental study design with control was adopted to determine the impact of CBCT in improving knowledge on birth preparedness and complication readiness. The study was conducted from June 2017 until March 2018. A multi-stage sampling technique was employed to obtain 561couples. Pre-test and post-training intervention information were collected using semi-structured questionnaires. The impact of CBCT was determined using both independent t-test and paired t-test. Linear regression analysis was used to establish the association between the project and the change in knowledge mean scores. The effect size was calculated using Cohen’s d. Results At post-test assessment, knowledge mean scores were significantly higher in the intervention group among both pregnant women (m = 14.47±5.49) and their male partners (m = 14.1 ±5.76) as compared to control group among both pregnant women (m = 9.09±6.44) and their male partners (m = 9.98±6.65) with large effect size of 0.9 among pregnant women and medium effect size of 0.66 among male respondents. When the mean scores were compared within groups among both pregnant women and male partners in the intervention group, there were a significant increase in knowledge mean scores at post-test assessment as compared to pre-test assessment with large effect size of Cohen’s d = 1.4 among pregnant women and 1.5 among male partners. After adjusting for the confounders, the predictors of change in knowledge among pregnant women were the CBCT project (β = 0.346, p<0.000) and ethnic group [Mambwe (β = -0.524, p = 0.001)] and the predictors of change in knowledge among male partners were the CBCT project (β = 1.058, p<0.001) and walking distance [more than five kilometers (β = -0.55, p< 0.05)]. Conclusion This interventional study which focused on knowledge empowerment and behavior change among expecting couples was both feasible and effective on improving knowledge about birth preparedness and complication readiness in rural settings of Tanzania. This section of the method has been partly published previously in the protocol titled The Effectiveness of Community-Based Continuous Training on Promoting Positive Behaviors towards Birth Preparedness, Male Involvement, and Maternal Services Utilization among Expecting Couples in Rukwa, Tanzania: A Theory of Planned Behavior Quasi-Experimental Study [23]. A quasi-experimental study with control using pre-post-tests was conducted to evaluate the effect of the CBCT project on improving knowledge on BPCR in a rural setting of Rukwa Tanzania from June 2017 to March 2018 [23]. The quasi-experimental study was conducted among expecting couples in Rukwa Region in the Southern Highlands of Tanzania. The region had a population of 1,004,539 people; 487,311 males and 517,228 females. The forecast for 2014 was 1,076,087 persons with a growth rate of 3.5%. The region has the lowest mean age at a marriage where males marry at the age of 23.3 years and 19.9 years for females and a fertility rate of 7.3 [24]. The sample size for couples who were involved in the study was calculated using the following formula [25] Where: n = minimum sample size Zα = Standard normal deviation (1.96) at 95% confidence level for this study 2β = standard normal deviate (0.84) with a power of demonstrating a statistically significant difference before and after the intervention between the two groups at 90% πo = Proportion at pre- intervention (Use of skilled delivery in Rukwa region 65%) [2] π1 = proportion after intervention (Proportion of families which will access skilled birth attendant 75%) n = 169 couples + 10% = 187 Therefore, the required sample size in the intervention group = 187 couples Intervention: control ratio = 1:2 (using age groups in five years and parity) which aimed at increasing comparability of these two groups. Therefore, the sample size in the control group = 374 couples. Two districts (Sumbawanga Rural District and Kalambo District) were purposively selected from the four districts of the Rukwa Region using the criterion of high home childbirth. Three stages of sampling technique (multistage) were used to enroll study participants in the study. In the first stage, all wards (12 wards of Sumbawanga Rural District and 17 wards of Kalambo District) were listed and a simple random sampling using the lottery method was used to obtain five wards from Sumbawanga rural district and ten wards from Kalambo rural district. In the second stage sampling, all villages from selected wards from each district were listed and a simple random sampling was used to obtain fifteen villages from Sumbawanga Rural District and thirty villages from Kalambo Rural District. The systematic sampling technique was finally used to obtain households that met the inclusion criteria (pregnancy of 24 weeks or below and living with a male partner). In each visited household, a female partner was assessed for the signs and symptoms of pregnancy. Research assistants who were nurses assessed for pregnancy. A female partner who had missed her period for two months was requested to complete a pregnancy test. Those with positive tests who gave consent to participate were enrolled in the study. If the visited household did not have eligible participants, the household was skipped and researchers entered into the next household. Step one of the project was pre training assessment of expecting couples. In step two, a total of fifteen village health workers were recruited for two days of training to empower them on knowledge about birth preparedness and complication readiness. On the second day, the village health workers discussed the available misconceptions about danger signs and how to address them during couple training. The training was concluded by providing training manual and reading materials for trainees (expecting couples). In step three, the actual couples’ training occurred where each expecting couple was visited for two days. Towards the end of the second day, they were assessed for comprehension of the sessions. The fourth step of the project was immediate assessment of knowledge after training. The fifth step was about the signs of labor and neonatal care. The teaching was initiated by revising the previous learned subject-birth preparedness then concluded by a discussion of misconceptions about signs of labor. The actual intervention was empowering expecting couples on danger signs and what to prepare for birth and obstetric emergencies. Teaching and learning materials were prepared using pictures to enhance understanding. Trainers were prepared on how to deliver the sessions and were provided with facilitation guides. Learners’ guides were prepared and were given to them for references. It was individualized couple’s training where each couple were trained at their households and were assisted to initiate birth plan (Fig 2). Semi-structured questionnaires were used for data collection. Trained research assistants interviewed the study participants and recorded their responses. Research assistants collected data both at pre-test and post-test assessment. Trained community health workers facilitated the four intervention sessions. The primary investigator coordinated the whole process of data collection. The first part had questions to measure knowledge of birth preparedness and complication readiness, questions were adapted and modified from monitoring BPCR tools for maternal and newborn health [26]. Several studies have adopted this tool [27, 28]. Pre-test assessment in both groups was done in June and July 2017, the intervention group was visited in October 2017 for immediate assessment of the intervention which was done from July to September. The post-test assessment in each group was done in February and March 2018. The collected data were assessed for completeness and consistencies, then they were coded and entered in to computer using statistical package IBM SPSS version 23. Frequency distribution and cross-tabulation were obtained using descriptive statistical analyses were used to describe the characteristic of the study participants. The linear logistic regression model was used to determine the predictors of change in knowledge mean scores from the pre-training assessment and post-training assessment. Both paired and independent t-test was used to measure the differences in mean scores between the pre-training and post-training assessment. The effect size of the differences in mean scores was determined using a Cohen’s d test. The proposal was approved by the Ethical Review Committee of the University of Dodoma. A letter of permission was obtained from the Rukwa Regional Administration. Both written and verbal consent was sought from study participants after explaining the study objectives and procedures. A couple was included into the study if both of them consented to participate in the study. Their right to refuse to participate in the study at any time was assured.