Assessing the acceptability of village health workers’ roles in improving maternal health care in Gombe State, Nigeria a qualitative exploration from women beneficiaries

Introduction Maternal, and under-five mortality rates in Gombe State are disproportionately high. The Society for Family Health (a Non-Governmental Organization) in collaboration with Gombe State Primary Health Care Development Agency implemented the Village Health Worker (VHW) Program in Gombe to address the low uptakes of maternal neonatal and child health (MNCH) services and reduced the impact of healthcare worker insufficiency. VHWs are lay indigenous women trained to educate and encourage women to use MNCH services, provide simple community-based maternal and new-born care through home visits, and facilitate facility linkage. We assessed the acceptability of VHW services among women beneficiaries of the Program. Methods Qualitative data were obtained through six focus group discussions with 58 women beneficiaries of the VHW program who delivered within the last 12 months preceding study period (October-November 2018). Themes explored were roles and acceptability of VHWs, and the influence of VHWs on the uptake of MNCH services. We analyzed data with NVivo 12, using Grounded Theory. Results Participants’ mean age was 25.1 (± 5.3) years old. Most participants 39 (67%), had been in contact with a VHW for at least 10 months. VHWs visited pregnant women at home and registered them for antenatal care, provided them basic maternal healthcare, health education, and facilitated facility linkage. Participants generally accepted the VHW Program because it was community-based, VHWs were indigenous community members, delivered clear messages, and influenced husbands and mothers-in-law to support women’s’ use of MNCH services. VHWs’ interventions were perceived to have improved health literacy and the uptake of MNCH services. Participants generally admired the VHW occupation and recommended VHW program scale-up, and for VHWs to be offered basic obstetric training and employment by health facilities or the government. Conclusion The general acceptance and positive views of VHWs from beneficiaries of the program demonstrates the feasibility of the program to improve the uptake of MNCH services. This was a cross-sectional qualitative study conducted employing focus group discussions among women of reproductive age beneficiaries of the VHW program residing in rural areas of Gombe State. Gombe State covers an area of 20,265sq, km [31], population is over 3.2 million (2016 estimate) [17], with approximately 136,000 births yearly [32], the State’s fertility rate (7.3) is higher than the national fertility rate (5.8) [33]. Uptake of facility antenatal (44.4%) and delivery (27.7%) [34], are lower than the national averages of 49.1% [35] and 39% respectively [34]. Hausa language is the inter-ethnic medium of communication, and the three common occupations are farming, cattle-herdsmen-ship and trading. Most residents (72.2%) live under 1USD/day [31], and literacy rates among males and females are 47.5% and 37.5% respectively [33]. The study population consisted of women residents of Gombe State who have benefited from the VHW Program. Society for Family Health monthly monitoring data on facility delivery uptake among VHW beneficiaries guided the selection of study VHW wards. After 23 months (October 2016 –September 2018) of VHW implementation, mean uptake of facility delivery services among VHW beneficiaries was 65% (±17.6%). The three wards that represented the maximum (Banganje North—96%), mean (Akko 65%) and minimum (Zange 23%) uptake of facility delivery services among the 57 VHW intervention wards, were selected for the study (Table 2). Women were eligible for the study if they had delivered either at home or in the facility 12 months prior the study period and were residents of the study selected wards: Baganje North, Akko, or Zange. (Table 2). Participants were recruited by Society for Family Health’s Program Officers through the VHWs. For each study selected ward, the Program Officer responsible for that ward purposefully selected a VHW who identified focus group discussion (FGD) eligible clients and verbally invited them to participate in the focus group. Recruitment was stopped once a target of 10 women had been reached for each FGD. Interested participants showed up for the FGD on the appointed date and time. For each selected ward, the first FGD targeted women who delivered in the facility (facility group), and the second FGD targeted women who delivered at home (home group). However, in Baganje North with an almost 100% facility delivery uptake, both FGDs consisted of women who delivered in the facility. Furthermore, the first Baganje North Group had only seven participants. Three participants were away at farm harvesting activities. While the second Baganje North Group had 11 participants because one of the three participants unable to join the first group joined the second group. In aggregate, there were a total of 58 participants, four facility groups (two from Baganje North, one from Akko and one from Zange) and two home groups (one from Akko and one from Zange). Seven bilingual (English and Hausa speakers) researchers were involved in data collection: author MAM (female, MPH, and over one year conducting and analysing qualitative data in a similar study setting and over 5 years research experience) was the Research Consultant responsible for the overall design and conduct of the study. Six Research Assistants who work as independent consultants: five female and one male were university graduates with a minimum of one year working experience facilitating FGDs on a number past VHW program evaluations which generally involved data collection from VHWs. The six Research Assistants also received one-day training facilitated by MAM in qualitative data collection for the purpose of the study and were financially remunerated for three days they were contracted for data collection. None of the researchers had prior contact or any kind of relationship with the FGD participants. A one-page 5-minute survey with open and close ended questions was designed to capture participants’ sociodemographic information (age, education, occupation), obstetric history numbers of facility and home deliveries and duration of contact with a VHW. For the FGD guide, multi-theme, semi-structed questions with probes were developed. Both data collection tools were updated after input were received through email from co-authors OS, BCO, BOO, IO and JA (Society for Family Health Staff directly involved with coordinating and monitoring the VHW program), to reflect their input of rephrasing the questions to accommodate the cultural context of study population. The first section of the FGD moderator guide explored topics on participants’ access, use, and satisfaction with facility delivery services. The second part of the guide examined roles of VHWs, and participants’ acceptability of the VHW program by asking questions on experiences/views on VHWs’ services, messages, communication skills, influence MNCH service use, and recommendations for the program. Hausa translated versions of both data collection tools were developed and those versions were used during data collection. This manuscript is reporting only data collected in the second half of the data collection tool that centered on roles and participant’s acceptability of VHW program. Ethical approval was obtained from the Gombe State Ministry of Health and all participants provided written or verbally documented consent. Prior to each FGD, one of the Research Assistants or MAM eloquently explained the content of the study information sheet and consent form to all participants in Hausa. After thorough explanation of the study information, participants were required to sign the consent to document that they have agreed to participate in the Study. Participants who were non-literate, were required to give the Research Assistants verbal consent to initialize the consent form and tick the verbal consent checkbox on their behalf. Participants were assured of their anonymity and that their response will not affect their interactions and/or care given to them by the VHWs and facility healthcare workers. All FGDs were audio recoded and notes taken with the consent of the participants. To maintain anonymity and establish a conducive atmosphere for discussion, participants used self-chosen aliases for each FGD. Researchers introduced themselves to study participants as independent consultants not affiliated with the VHW program or the health facility, and the reason for conducting the study was to improve VHW services. Prior to the commencement of FGDs, sociodemographic information of each participant was collected by administering the 5-minute survey in Hausa language. In total, six FGDs were conducted: two FGDs per ward. MAM and two Research Assistants conducted each of the FGDs. First Research Assistant and MAM moderated and co-moderated the discussion, while the second Research Assistant observed the discussion and noted participants’ non-verbal cues and synergistic group effects. Discussions were conducted either in open outdoor settings or private rooms within the premises of a selected health facility during non-working hours. Only researchers and participants were present during FGD discussions. All FGDs were conducted in Hausa, audio recoded, and notes taken with the consent of the participants. No repeat FGDs were conducted, and participants were not required to give feedback on findings. Duration of FGDs ranged from 40–90 minutes and participants were given refreshment worth NGN 500 ~ USD1.3 (at exchange rate ₦365 to USD1) at the end of the FGDs. The qualitative study time was 30th October 2018 to 1st November 2018. Daily debriefing sessions were held with data collectors to discuss findings and identify saturation of themes. The target was to conduct six FGDs with the plan to conduct more in the instance of non-saturation of data. However, conducting more FGDs was not required as data saturation was reached within the six FGDs. Audio-recorded FGD transcripts, signed informed consent forms and completed socio-demographic surveys were filed and locked in a secure cupboard and were only accessible to the research team. Socio-demographic data were analysed with Microsoft excel formula function: age mean, and age standard deviation were calculated. Other information was presented in aggregate and percentages (Table 3). SD–Standard Deviation aBaganje North Facility Group 1 bBaganje NorthFacility Group 2 cAkko Facility Group 3 dAkko Home Group 4 eZange Facility Group 5 fZange Home Group 6 gIslamic or Bible School hone TBA iInclude four Boboriya, three Hausa, five Karekare, three Bolewa, two Kanuri one Waja and one Tera All six focus groups were conducted in Hausa. The six Research Assistants who conducted and observed the FGDs translated and manually transcribed the FDGs into English. For quality control, after the transcription of the first 2 FGDs, MAM reviewed the transcripts against the respective audio recordings to verify the quality of the translation and transcription. As transcriptions were considered satisfactory, the transcription process was continued. All the six transcripts were coded by the MAM using NVivo 12 (Pro for Windows), using the principles constant comparative method in grounded theory (to capture a broad range of participants’ perspectives without any preconceived notions or theories about these perspectives) [36]. The constant comparative method involves using inductive methodology to systematically generate theory from data. A combination of emerging codes from the data and pre-set codes generated from the FGD guide formed the root of the coding tree. The root pre-set code words for the coding tree were “roles of VHWs,” “VHW visits,” “VHW messages understood,” “VHW as community members,” “Questions asked VHWs,” “likes about VHWs,” “admire VHWs,” “VHWs working hard,” “encourage ANC and facility delivery,” and “dislike about VHWs.” All transcripts were analyzed through inductive theme analysis until all emerging themes are exhausted. Thereafter, the second author: SO analysed about 30% of the transcripts. There was an 85% inter-ratter agreement between the two coders (MAM and SO). Subsequently, the coding outcomes were shared through email on a power point presentation with co-authors: OS, BCO, BOO, IO and JA to consolidate codes into categories, and to identify overarching themes and sub-themes. A detailed report was provided alongside a presentation to Society for Family Health in April 2019.