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Sociocultural Factors Shaping Trust and Teamwork among Community Maternal and Newborn Health Workers in Rural Ethiopia

Dynes, Michelle (2013)
Dissertation (172 pages)
Committee Chair / Thesis Adviser: Sibley, Lynn M
Committee Members: Hadley, Craig ; Stephenson, Robert ; Risjord, Mark
Research Fields: Health Sciences, Nursing; Health Sciences, Public Health; Anthropology, Medical and Forensic
Keywords: Trust; Teamwork; Community Health Workers; Ethiopia; Heterogeneity; Health Services; Health Systems Research; Motivations; Maternal Health
Program: Laney Graduate School, Nursing
Permanent url: http://pid.emory.edu/ark:/25593/d6bfn

Abstract

Task shifting in response to the health workforce shortage has resulted in community-based health workers taking on greater responsibility. Research suggests that collaboration among coworkers increases performance and that trust plays a role in collaboration. Most of this research in health services has taken place in clinics and hospitals in high-income countries. Moreover, little is known about the way trust is conceptualized among health workers in low-resource areas or how to measure trust in these settings. We addressed these gaps by carrying out in-depth interviews with community health workers in rural Ethiopia to better understand their conceptualization of trust, and to develop and test a scale to measure trust among them. We built upon this research by conducting a cross-sectional, social network survey of community health workers in rural Ethiopia to explore the factors shaping teamwork. We employed fractional logit regression modeling to identify the influential factors for work interactions with each cadre of health workers. We also examined the dyadic factors for interactions through analyses of social network data using the Double-Dekker Semi-partialing Multiple Regression Quadratic Assignment Procedure. Formative work uncovered a core set of items that seemed to define trust in the study context--character, communication, and ability--in addition to locally-relevant ways of thinking about trust ('oneness'). In pilot testing, our 10-item Rural Health Worker Trust Scale maintained strong internal consistency and the hypotheses to test for criterion and contrasting group validity were upheld. Results of fractional logit modeling revealed that being a Health Extension Worker, a male health worker, and trusting a cadre were important factors for work interactions with all three cadres. Analyses of social network data demonstrated consistently strong evidence across study sites in support of interpersonal trust and training together as important factors for dyad-level interactions. Findings suggest that inter-professional training focused on fostering trust and gender sensitivity, and improving perceptions of health worker motivations, may be particularly effective in promoting collaboration among diverse community health workers. Future research should focus on large-scale, longitudinal studies aimed at understanding how teamwork changes in response to fluctuations in trust, motivations, and gender norms over time.

Table of Contents

Chapter 1 - Introduction..............................................................................1

Figure 1.1..................................................................................................9

Figure 1.2.................................................................................................10

Figure 1.3.................................................................................................17

Chapter 2 - Measuring Trust among Frontline Health Workers in Rural Ethiopia...40

Table 2.1...................................................................................................71

Table 2.2...................................................................................................72

Table 2.3...................................................................................................73

Table 2.4...................................................................................................74

Table 2.5...................................................................................................75

Table 2.6...................................................................................................76

Chapter 3 - Factors Shaping Interactions among Community Health Workers in Rural Ethiopia: Rethinking "Workplace" Trust and Teamwork....................................77

Table 3.1..................................................................................................105

Table 3.2..................................................................................................106

Table 3.3..................................................................................................107

Table 3.4..................................................................................................108

Figure 3.1.................................................................................................110

Chapter 4 - A Network Study Exploring Factors that Promote or Erode Interaction among Diverse Community Health Workers in Rural Ethiopia.....................................111

Table 4.1..................................................................................................139

Table 4.2..................................................................................................140

Table 4.3..................................................................................................141

Table 4.4..................................................................................................143

Table 4.5..................................................................................................144

Figure 4.1.................................................................................................145

Chapter 5 - Discussion and Conclusion..........................................................146

Figure 5.1.................................................................................................153

Figure 5.2.................................................................................................157

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