Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: Community experiences from Masindi and Kiryandongo districts, Uganda Global health.

Background: Home visits by Community Health Workers [In Uganda Community Health Workers are given the collective term of Village Health Teams (VHTs). Hereafter referred to as VHTs] is recommended to improve maternal and newborn care. We investigated perceived maternal and newborn benefits of home visits made by VHTs, combined with mobile phone consultations with professional health workers for advice. Methods: A qualitative study was conducted in Masindi and Kiryandongo districts, Uganda, in December-2013 to March-2014. Study participants were drawn from the intervention arm of a randomised community-intervention trial. In-depth interviews were conducted with 20 prenatal and 16 postnatal women who were visited by VHTs; 5 group discussions and 16 key informant interviews were held with VHTs and 10 Key Informant Interviews with professional health workers. Data were analysed using latent content analysis techniques. Results: Majority women and VHTs contend that the intervention improved access to maternal and newborn information; reduced costs of accessing care and facilitated referral. Women, VHTs and professional health workers acknowledged that the intervention induced attitudinal change among women and VHTs towards adapting recommended maternal and newborn care practices. Mobile phone consultations between VHTs and professional health workers were considered to reinforce VHT knowledge on maternal newborn care and boosted the social status of VHTs in community. A minority of VHTs perceived the implementation of recommended maternal and newborn care practices as difficult. Some professional health workers did not approve of the transfer of promotional maternal and newborn responsibility to VHTs. For a range of reasons, a number of professional health workers were not always available on phone or at the health centre to address VHT concerns. Conclusions: Results suggest that home visits made by VHTs for maternal and newborn care are reasonably well accepted. Our study highlights potential benefits of combining home visits with phone consultations between VHTs and professional health workers. However, the challenge of attitudinal change among VHTs towards certain strongly culturally-embedded behavioural post-partum practices, resistance from part of the professional health workforce to collaborate with VHTs and the problematic availability of professional health workers are important systemic problems that need to be addressed. Trial registration: Current Controlled Trials NCT02084680.Registered 14 March 2014. This was a qualitative enquiry that employed In-Depth Interviews, Key informant interviews and Group discussions. Study participants were drawn from prenatal-, postnatal women, VHT members and professional health workers. All study participants were part of the intervention arm of the community intervention study. Briefly, the intervention was a community intervention trial in which 16 health centres were randomly and equally allocated to control and intervention arms. The control arm received health educational messages routinely offered at the health facility, while the intervention arm received VHTs who conducted home visits and were equipped with mobile phones for consultation with professional health workers for advice. The community intervention trial study is registered with ClinicalTrials.gov ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT02084680″,”term_id”:”NCT02084680″}}NCT02084680). This study was conducted in Masindi and Kiryandongo districts Uganda, from December 2013 to March 2014. This region is located 214 kilometres northwest of the capital Kampala. Eighty per cent of the population lives within five-kilometres walking distance to the nearest health centre. About 97 % of pregnant women make at least one antenatal care consultation and 52 % make four antenatal consultations, but less than 50 % deliver with the help of a skilled attendant [7]. In this region, VHTs have been selected and trained by their respective health departments on basic health promotion and community mobilization. In Uganda, community members nominate male or female volunteers to serve as VHTs. For this study VHTs were selected from pre-existing VHT members. Prenatal women for in-depth interviews were drawn from five of eight intervention health centres. The number of five health centres was considered logistically feasible. Twenty prenatal women (four from each health centre) who were antenatal attendees and enrolled into the intervention arm were purposively selected to participate in the in-depth interviews. Purposive selection of prenatal women was preferred to ensure synchronised postnatal in-depth interviews with the same women. Therefore, inclusion into the first in-depth interview was based on prenatal women having similar expected dates of delivery. Records of expected dates of delivery were obtained from personal files of enrolled women. All VHTs serving in the coverage area of five selected health centres were included in the group discussions. Group discussions included 5 VHTs each. Two VHTs each from the eight catchment health centres of the intervention arm were selected for key informant interviews. Ten professional health workers who were directly involved with the offer of prenatal, intra-partum and postnatal care in the intervention health centres were selected for key informant interviews. Different category of respondents and qualitative techniques were included to allow for data triangulation. Five social scientists experienced in qualitative interviews and familiar with the local dialects, but not part of the study team conducted the interviews. Interview questions explored perceived benefits of the intervention from the perspective of VHTs, prenatal and postnatal women and professional health workers (see Additional files 1 and 2). Perceptions of postnatal women and VHTs towards recommended essential newborn care practices were explored (see Additional file 3). We explored women and VHTs opinions regarding adherence to non-application of substances on the cord, delayed bathing of the newborn for three days and initiation of breastfeeding within one hour and avoiding pre-lacteal feeds. Professional health workers were asked how they perceived the transfer of promotional maternal and newborn care responsibilities like home visits to offer health education to VHTs (see Additional file 4). Interview questions were open-ended to allow free expressions by respondents and further probing by interviewers. All interviews lasted 60–90 min. A total of 67 interviews were conducted. Thirty six in-depth interviews were conducted with women; five group discussions with VHTs and 26 key informants (16 VHTs and 10 professional health workers). Four out of the initial 20 women could not be located during the postnatal period. Prenatal and postnatal in-depth interviews with the women were conducted in their homes. Group discussions and Key informant interviews were conducted at the health centre [See details in Table 1]. Trends of data collection Interviews were audiotaped and transcribed directly into English. Typed texts were read several times and exported to NVivo version 10. Analysis was by latent content analysis. As defined by H-F Hsieh and SE Shannon [22], latent content analysis involves subjective interpretation of text data through systematic classification process of codding and identifying themes or patterns [22]. This approach provides a deeper knowledge and understanding of the phenomenon under study in this case perceived benefits of the intervention. We preferred the directed latent content analysis because our analysis was based on pre-existing theories about home visitation by VHTs and mobile phone consultations, permitting the use pre-determined codes, also allowing for the emergence of new codes [23]. Predetermined codes included: perceived benefits of home visits and mobile phone consultations, perception and experiences of women and VHTs towards recommended maternal and newborn care practices; professional health worker perception regarding transfer of promotional maternal and newborn care to VHTs. Sub themes were developed under each code and summarized into meaningful text from which main themes were developed. Quotes were included to emphasis specific sub-themes (See Table 2 for summary of results). Analytical framework In this analysis home visits by VHTs and mobile phone consultations were considered a single intervention. Therefore perceived benefits of the intervention were reported as effect of one intervention. Where applicable, views from different respondents considered to be describing the same sub-theme, whether convergent or divergent were presented under the same sub-theme. A written consent was secured at the time of enrolment of prenatal women into the community intervention study. The pre-enrolment consent detailed, home visits by VHTs and women’s participation in subsequent interviews. During this study women were reminded of their prior consent to participate in the study and verbal consent was obtained before conducting interviews. All women that were approached for the interviews accepted to participate. All VHTs and professional health workers provided verbal consent to participate in this study. Confidentiality was maintained throughout the interviews and results are reported to ensure anonymity. This research was approved by the Higher Degrees, Research and Ethics Committee of Makerere University School of Public Health, College of Health Sciences and the National Council of Science and Technology in Uganda.