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

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

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	community health worker maternal health
Committee Chair / Thesis Advisor	Stephenson, Robert, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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