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Despite decades of training health workers in communication, complaints from clients and communities about poor health worker attitudes abound. This was found to be so in Zambia where the More Mobilizing Access to Maternal Health Services in Zambia (MORE MAMaZ) program was trying to ensure the inclusion of under-supported women in a community-based maternal and newborn health program in five intervention districts. Under-supported women suffer a disproportionate burden of child mortality and are poor users of health services. An exploratory small-scale qualitative survey involving nurses from training schools and health facilities found that nurses knew how to communicate well, but were selective with whom and in what circumstances they did this. In general, those who received the worst communication were under-supported and had low confidence—the very people who needed the best communication. An experiential training program was started to help health workers reflect on the reasons for their poor communication. The training was evaluated after 14 months using semi-structured interviews and focus group discussions with staff at participating health facilities. The results showed improved inclusion of under-supported women but also increased attendance generally for ante-natal clinics, deliveries and under-five clinics. Another outcome was improved communication between, and a sense of job satisfaction among, the health workers themselves. The program demonstrated an effective way to improve the inclusion and involvement of the least-supported women and girls. There are important lessons for other health programs that aim to operationalize the goals of the Global Strategy for Women’s, Children’s and Adolescent’s Health, which include an emphasis on reaching every woman.
In Zambia, the immediate impetus to train nurses and other front-line health workers in communication skills in the MORE MAMaZ intervention sites arose from persistent complaints from community members and health managers concerning the poor attitudes of health workers to clinic attenders. The concern was that this gap in the quality of care would impact negatively on the demand creation efforts that were underway at community level. Before beginning the training intervention, an effectiveness review of current communication training programs and a perspectives survey with health care workers were conducted. It was found that the Zambian nurse training program emphasized communication theory and practical applications similar to other programs around the world without taking into account the possibility that communication can be selective [11,12,13]. The underpinning assumptions were that not all health workers communicated badly; and those that did, communicated badly with all of their clients. However, there were no long-term evaluations of program effectiveness. Conversely, the pilot survey with Zambian healthcare workers found that while they knew how to communicate well, they applied these skills selectively. These findings challenged some long-standing assumptions about health worker communication skills. The understanding gained from the survey of nurse communication practices was used to plan a three-day training of health staff working in 64 health facilities in the program’s five intervention districts. The districts were Chama district in Muchinga Province; Mkushi, Serenje and Chitambo districts in Central Province; and Mongu district in Western Province. Curricula for core trainers (District Health Management Team (DHMT) members and nurse tutors) and for step-down training were devised with nurse tutors and Zambian consultants. The step-down training was designed to be delivered in two stages: first, a training of selected front-line health workers in participating health facilities, and, second, an orientation by the latter of other health workers in the facility, and also of Community Health Volunteers (CHVs) and other community members. The second group received a one-day step-down training. The training of CHVs and community members was important not only to help with the local identification of the least-supported women, but also to encourage those women to attend health services and to join groups. It also helped to better integrate the social inclusion work of the CHVs with that of the clinic-based health workers. The program used an experiential training approach in which health workers reviewed themselves and developed insights into why they chose to communicate badly in some instances, whilst communicating well in others. The idea was that they would then be able to review how to manage and control the factors that led to instances of poor communication in their work setting. A starting point for reflection and discussion was the notion that the very people with whom health workers were most likely to communicate badly were those most likely to suffer ill health, or to have children who suffered ill health. The results of the nurse survey indicated that the use of general categories for targeting (e.g., ‘poverty’ or ‘lack of education’) was less useful than having an understanding of a client’s social situation at home. In other words, health workers needed to understand more about the underlying factors that led to a client presenting as poorly dressed, unwilling to communicate or shy. Health workers were also encouraged to think about the impact of poor communication on patients and on their colleagues—a topic not generally covered in formal health worker communication training. The need to improve communication between staff had not featured among the concerns cited by district health managers. This appeared to be a neglected area in supervision and management systems generally. The essential steps in the three-day training were: An evaluation of the training was undertaken in November 2015, 14 months after the first training input. The evaluation included 61 percent of participating health facilities (20 of 33 health facilities) in three of the five program districts: Chitambo, Serenje and Mkushi, all in Central Province. The evaluation was conducted with the full participation and involvement of the respective DHMTs. Due to the staggered nature of the step-down training, health center staff, CHVs and community members received their training between seven and 12 months prior to the evaluation. A total of 20 health centers participated in the evaluation (eight in Chitambo, four in Serenje and eight in Mkushi). Semi-structured interviews were conducted with staff at the health centers, members of the DHMTs and the trainers. Focus group discussions were also carried out with CHVs and community representatives who were members of Neighborhood Health Committees. In each district, two teams of three interviewers conducted the interviews. A member of the DHMT was included on the interview team to improve relevance. In the health centers, 35 staff who had been trained (or oriented by other staff) were interviewed in addition to 22 CHVs. For 19 of the 20 health centers, a selection of community members (10–12 in each group) was also interviewed. The interview questionnaires were designed separately for core trainers, health facility staff, CHVs, and community members. Each questionnaire had two components. The first set of questions was asked directly of interview respondents. These were fully open-ended to prevent bias towards a positive response. The answers were analyzed and coded by the evaluator for the main categories of response in relation to changes in communication, focus on under-supported women and changes in community support of the under-supported. The second set of questions was answered by the interviewer directly after the interview. These allowed the interviewer to check whether specific aspects of the training or experience had been mentioned, were implicit in the answers given by a respondent, or not mentioned. The answers were then appropriately coded. For this category of questions, the interviewer’s answers were checked against the respondent’s answers at the data analysis stage. The teams of interviewers were given a one-day orientation on how to ask open-ended questions without giving any intimation of an expected answer. They also learnt how to assess what was implied in an answer, how to probe for fuller answers without directing them, and how to use the questionnaires. At the end of every day of interviewing, each team met to review the answers, and to provide their own feedback on what they had seen and heard. Data was entered into Excel spreadsheets. Coded data was analyzed using the SPSS statistical package. A wide selection of the interviewee responses was provided in the evaluation. In order to contextualize the findings, the training evaluation examined in detail the government health statistics for each of the clinics visited, and compared these with areas where no training had taken place. For each area, the answers from the different types of respondents were cross-checked for consistency (e.g., the responses of clinic staff were checked against the perceptions of community members and CHVs). The DHMTs from all intervention districts were invited to perform their own assessments of the training intervention before the evaluation. They were also invited to present these, together with their recommendations for future work, in a dissemination workshop involving donors, government representatives and other organizations. Ethical approval was obtained as part of the overall approval given by the Zambian Ministry of Health for the operations research study as a whole. There were few methodological limitations to the measurement of the impact of communications training to staff in clinics as the correlation between the answers of different staff (interviewed separately) at any particular clinic was very high. The clinics had been given no previous warning of the evaluation team visits, nor of the types of questions they would be asked. However, a failure to separate CHVs from other community representatives during focus group discussions meant that it was difficult to avoid positive bias in the answers as there was a tendency for the CHVs to answer in advance of others. This was dealt with by asking community members to answer first. However, this was not always successful.
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