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Self-Efficacy and Delivery Service Provision among Community Health Workers: Lessons from Rural Ethiopia

Handley, Anna Lynn (2011)
Master's Thesis (119 pages)
Committee Chair / Thesis Adviser: Stephenson, Robert
Committee Members:
Research Fields: Health Sciences, Public Health
Partnering Agencies: Emory University schools, faculty or affiliated programs
Keywords: community health worker; maternal health
Program: Rollins School of Public Health, Hubert Department of Global Health
Permanent url: http://pid.emory.edu/ark:/25593/92msg

Abstract

Background: Efforts to reduce maternal and newborn mortality in Ethiopia have been slow moving, in part because of limited health infrastructure. In response to the inaccessiblity of services, the Health Extension Program was created in 2003, and has deployed nearly 30,000 community health workers. Mothers and newborns are at greatest risk for negative health outcomes during birth and accordingly, most community health workers received training in the delivery of normal births. The training is primarily theoretical, and few CHWs are provided with delivery experience. Due to limited monitoring, it is unclear how prepared CHWs are to attend delivery amidst competing health responsibilities. Objective: This study explores the factors than enable community health workers to provide delivery care in Amhara region, particularly emphasizing the association between self-efficacy and the prioritization and self-marketing of delivery services. Methods: Twenty-six in-depth interviews and 162 surveys were conducted with Health Extension Workers, voluntary Community Health Workers, and traditional birth attendants in Amhara region, Ethiopia to assess current patterns of delivery care provision and factors that enable the provision of delivery care. Results: The survey reveals that despite formal training in delivery, many community health workers are not providing delivery services. Self-efficacy was found to be strongly associated with the provision of delivery care. Formative interviews indicate that experience with delivery promoted a sense of self-efficacy among community health workers, which prompted self- marketing of services, and increased the number of notification pathways for labor or pregnancy-related complications. Self-efficacy, when coupled with regular interaction with TBAs further increased the number of notification pathways. Discussion: Community health workers in rural Ethiopia have life saving knowledge and skills, but are often not in the right place at the right time to fully utilize their abilities. Mechanisms to get community health workers into the homes of women in labor or with complications need urgent exploration. This study offers emerging evidence that building self-efficacy through experience with delivery is critical for health workers to prioritize and self-market of delivery services. Furthermore, regular interaction with traditional birth attendants enhances the probability that community health workers will be notified of labor or pregnancy-related complications.

Table of Contents

1 - INTRODUCTION............................................................................................... 1 -- Problem Statement ............................................................................................... 1 -- Objectives and Aims .............................................................................................. 3 -- Background of Ethiopia .......................................................................................... 3 -- Ethiopia's Health System ........................................................................................ 5 -- Host Organization ................................................................................................. 11 -- Summary.............................................................................................................. 13 -- 2 - LITERATURE REVIEW......................................................................................... 14 -- Community-based Maternal and Newborn Health Interventions ................................... 14 -- Elements of Success and Failure............................................................................... 17 -- Theoretical Frameworks and Community Health Worker Training................................... 28 -- 3 - METHODS ........................................................................................................ 34 -- Program Background .............................................................................................. 34 -- Study Setting ........................................................................................................ 36 -- Research Design .................................................................................................... 37 -- Data Analysis......................................................................................................... 42 -- Reflections on Data Quality ...................................................................................... 43 -- 4 - RESULTS (Qualitative) ........................................................................................ 45 -- Descriptive Statistics ............................................................................................... 45 -- Frontline Health Worker Roles and Responsibilities........................................................ 45 -- Determinants and Implications of FLW Team Identity .................................................... 52 -- Determinants of Delivery Care Among CHWs................................................................ 59 -- Additional considerations ........................................................................................... 66 -- Limitations .............................................................................................................. 67 -- 5 - RESULTS (Quantitative) ....................................................................................... 68 -- Introduction and Data Quality .................................................................................... 68 -- Population Characteristics .......................................................................................... 68 -- Patterns and Prioritization of Community-based MNH Service Provision............................. 71 -- Patterns of Community-based Delivery Service Provision................................................. 73 -- The Association between Confidence and Delivery Service Provision ................................. 74 -- Associations with Confidence in and Provision of Delivery Care ........................................ 78 -- Key Components of Confidence ................................................................................... 83 -- Summary.................................................................................................................. 90 -- 6 - DISCUSSION........................................................................................................ 92 -- Summary of Results................................................................................................... 92 -- Relationship to the Literature ...................................................................................... 95 -- New Findings ............................................................................................................ 99 -- Public Health Recommendations .................................................................................. 103 -- Training ................................................................................................................... 103 -- Post-training strategies .............................................................................................. 104 -- Involvement of TBAs.................................................................................................. 105 -- Quality improvement frameworks................................................................................. 105 -- Conclusion ................................................................................................................ 107

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