ABSTRACT
Maternal,
new-born and child mortality have been on the front burner of public health
policy makers and implementers for decades especially
in developing and under developed countries. The inclusion of Maternal,
New-born and Child Health (MNCH) targets in the Sustainable Development Goals
(SDG) highlights the enormity of the challenge and the efforts taken towards
reducing maternal, new born and child mortality in Africa. The MNCH training
for health promoters was developed towards improving health promoters’
performance; thus a reduction in maternal and infant mortality. The study
therefore examined the influence of training on the performance of health
promoters in maternal, newborn and child health education.
Triangulation research design was adopted for the
study. The study population comprised 155 health promoters and 43000 mothers in
Akwa Ibom State. Multi-stage sampling technique was used to select 125
respondents. Questionnaire, Interview Guide and Focus Group Discussion Guide
were the instruments used for data collection. Data collected was summarized, coded, analyzed and
presented using frequency distribution tables;charts were generated for the
variables. Qualitative data was transcribed, coded and synthesized based on prevalent
themes expressed by the interviewees. Multiple linear regression analysis was
used to test the hypothesis.
Findings
revealed that health
promoters in Akwa Ibom used flipcharts, diagram boards, slides, manuals and papers
designed specifically for MNCH training. The training environment and duration
were discovered to be inadequate for training of health promoters. The instruments
of social mobilization used by health promoters were identified as mass media,
local traditional heads and mothers’ word of mouth. However, findings from the
respondents indicated that socialization was averagely low in the aspect of
door to door counselling, involvement of mothers in implementation and
monitoring of MNCH programmes. Health promoters noted that the health
behaviours of mothers have been positively impacted by health messages
disseminated to them. It was discovered the mothers revealed that mothers’
health behaviours were impacted upon by the health promoters, but disagreements
exist in the aspect of exclusive breastfeeding where some mothers found it
difficult to breastfeed exclusively for six months. From the test of hypotheses
with a 0.05 pre-set level of significance, it was discovered that health
education and/or social mobilization did not significantly influence mothers’ health
behaviour.
The study concluded that the training
for health promoters in Akwa Ibom state is to an extent deficient as the health
promoters do not significantly influence mothers’ health behaviour. A major
obstacle for the MNCH campaign planning and execution was discovered to be
funding. This study therefore recommends that health promoters should identify
sustainable ways of financing health trainings. Also, consideration should be
given to selecting the training environment to ensure proper spacing and
suitability for learning. The techniques and strategies for socialization and
health education should be revisited in Akwa Ibom State with a strong framework
included for testing mothers’ adoption of the health information as a
measurement of health promoters’ level of efficiency.
CHAPTER ONE
INTRODUCTION
1.1Background to the Study
Nigeria
accounts for about ten percent of maternal deaths in the world with an
estimated 814 maternal deaths for every 100,000 live births (World Bank, 2015).
The morbidity and mortality among children in Nigeria is 10,900 per 100,000 live births and the infant
mortality rate (IMR) which is at 6,900 per 100,000 live births is still higher
than many other countries in Sub-Saharan Africa with similar GDP as made known
by WHO (2015). Maternal New-Born and Child mortality have been on the front
burner of public health policy makers and implementers for decades. Ogunjimi,
Ibe and Ikorok (2012) define maternal death as the “death of women while
pregnant or within 42 days of termination of pregnancy irrespective of the
duration and site of the pregnancy from any cause related to, or aggravated by
the pregnancy or its management but not from accidental or incidental causes”
(P.34). Child mortality “is the death of a child under five years, while infant
mortality is the death of a child under 1 year” (WHO, 2006; 2).
Illnesses
during pregnancy or within forty-two (42) days of termination of pregnancy as
well as pregnancy management issues contribute to maternal death. Some of the
acute illnesses that lead to maternal mortality are anaemia in pregnancy due to
malaria, intra-partum and post-partum hemorrhage, sepsis, obstructed labour,
and hypertensive conditions in pregnancy. However, Pneumonia, malaria, and
diarrhea, under nutrition and malnutrition, are major causes of childhood
morbidity in Nigeria. It is estimated that 24% of children under five (5) years
of age are underweight and 36% of children are estimated to be stunted (WHO,
2015).
The
enormity of the challenges of maternal new-born and child health issues
influenced the creation of the Millennium Development Goals (MDGs) and the
subsequent Sustainable Development Goals (SDGs). According to the WHO (2014),
for an increased success rate of achieving the number four (4) (reducing child
mortality) and number five (5) (improve maternal health), MDGs were highly
needed because of the encouragement noted in the reduction in global child and
maternal deaths (50%) from 1990 (baseline for the MDGs). Despite the efforts
put into achieving the goal of reducing maternal mortality and infant morbidity,
women and children across the world still die from preventable illnesses. The inability to realize the MDG’s objective
of reducing maternal and child mortality led to the Maternal New Born and Child
Campaign in Nigeria as part of the Sustainable Development Goals - SDG’s (National
Primary Health Care Development Agency, 2015). The Maternal New-born and Child
Health campaign adopted development communication activities supported by
trainings for health promoters in an attempt to boost their performance.
Health
communication research has helped to increase health promoters’ and care providers’ awareness and
performance, contributed to building national health policies, provided
theoretically driven framework (Ogunjimi et al 2012), however, more tools are
still needed to improve performance of health promoters.Lincetto,
Mothebesoane-Anoh, Gomez, and Munjanja (2016) suggests that health promoters
need to be effective in a variety of contexts and situations; such as updating
and disseminating accurate maternal and new-born health information in order to
be able to promote healthy behaviours, healthy lifestyles and diet, safety and
injury prevention, support and care, preventive interventions, care seeking
behaviour, recognition of danger signs for the woman and the newborn. As a tool
for improving child and maternal healthcare, the federal Government of Nigeria
through the National Council on Health in 2010 adopted a week long bier-annual
(May and November every year) implementation of the MNCH week in Nigeria
against the backdrop of unacceptably poor maternal and under-5 health indices
in Nigeria. This was made as strategy to interrupt and reverse the trend of
poor maternal, newborn and child health indices. As part of the efforts to ensure
that effectiveness of the health intervention/promotion activity, trainings are
organized during the MNCH week for health workers and promoters.
Training
has been identified to increase health workers’ performance, this is because it
is vital for their development and effectiveness (Khan, Khan, & Khan, 2011).
An increase in the performance level of health promoters and workers directly
influences an increase in the performance of the health sector. Zaman, Ashraf
and Martines (2008) in their study demonstrated the importance of training in
improving the communication and counseling skills of health workers towards
improving children’s nutritional status. In the MNCH campaign, training of
health promoters is required because of the sensitivity of the information
being shared and the accuracy that must accompany its application or adoption.
Consequently, an increase in the level of performance of health promoters can
influence patients’ health behaviours, and the
conditions that affect their health status and the health status of new-born
and children. As such, the mothers’ level of health education received from the
health promoters, as well as level of social mobilization to use MNCH services
provide an indirect way of measuring health promoters’ performance.
Health
promoters are very crucial because they are needed in the intervention programmes
for maternal newborn and child health campaign. The National Primary Health
Care Development Agency has a training manual developed for implementing
maternal, newborn and child health in Nigeria, this was necessitated because of
the evaluation of the progress towards achieving 2015 MDG targets showed that
Nigeria still had high maternal, newborn and child mortality rates, with
overall annual reduction still very low; the training manual was thereby
developed to build the capacity of the health workers for implementation of the
MNCH campaign. The maternal, newborn and child health campaign in Nigeria run
the following interventions: immunization, nutrition, malaria control, focused
ante-natal care and health promotion (health education/ social mobilization).
Health promotion
comprises of health education and social mobilization in the maternal, newborn
and child health campaign. Health promotion is a development communication
activity targeted at women aged 15 to 49 years and include the following as activities:
social mobilization (immunization) and health education (exclusive
breastfeeding, complementary feeding, supplementary feeding, hygiene and HIV
prevention) for expectant and nursing mothers. These intervention programs
require acquisition of skills in order to ensure the achievement of set goals
and objectives of the health campaign. Social mobilization and Health education
towards achieving reduction in maternal newborn and child mortality are important;
(Lincetto et al., 2016) observe that social, family, and community contexts,
practices and beliefs can influence women’s health during pregnancy either
positively or negatively. They further pointed out that some cultures promote
special foods and rest for pregnant women, but in others, pregnancy is not
given special importance and they make these pregnant women to work hard and
might even impose nutritional taboos on them thereby increasing the mortality
probability of pregnant women. In such cases, the health promoters are expected
to use their health education skills acquired during the maternal newborn and
child health campaign training to advice and support such a woman and her
family for developing healthy behaviours, birth and emergency preparedness to
increase awareness of maternal and newborn health needs and self- care during
pregnancy and the postnatal period, including the need for social support
during and after pregnancy. Health promoters are also needed to promote and
support care seeking behaviour, including recognition of danger signs for the
woman and the newborn as well as transport and funding plans in case of
emergencies, helping the pregnant woman and her partner prepare emotionally and
physically for birth and care of their baby, particularly preparing for early
and exclusive breastfeeding and essential newborn care and considering the role
of a supportive companion at birth. Hence, this study tends to probe into the
influence of training on the performance of health promoters in Maternal
New-born and Child Health Education for mothers in Akwa Ibom State.
1.2 Statement of the Problem
Nigeria
has been identified as a country where maternal and new-born mortality is
endemic. The fight against the increase in maternal and new-born mortality rate
has been decentralized to states to ensure better coordination, efficiency and
effective allocation of human and other resources towards achieving Maternal
Newborn and Child Health campaign strategic goals. The goals are to “Contribute to health
systems strengthening through improved promotion, delivery and utilization of
health and nutrition services by women and children and also to improve the
capacity of health workers to deliver good quality services” (Nigeria National
Primary Health Care Development Agency, 2015).
However,
despite the fact that MNCH campaign trainings have held over the years since
2010, the rate of Maternal Newborn and Child mortality in Nigeria is still high
(WHO, 2015; World Bank, 2015). Prior to the commencement of the MNCH week in
2010, maternal mortality figures stood at 864/100,000 as against 814/100,000 in
2015; a figure which is still very high (WHO 2015). The WHO report in 2015
showed that mortality among children in Nigeria is also very high with figures at
10,900 per 100,000 live births and the Infant Mortality Rate (IMR) at 6,900 per
100,000 live births. Despite the record of decline in maternal and infant
mortality rates since the commencement of the Maternal Newborn and Child Health
pre-campaign training, these figures are still high suggesting that the
training has improved performance but perhaps not at the rate expected after
five (5) years .
In Akwa
Ibom State for example, the infant Mortality Rate stands at 8,400/100,000 live
births, under 5 years mortality is 13,800/100,000 while Maternal Mortality Ratio
is 545/100,000 (Akwa Ibom State Ministry of Health, 2013). Since the Maternal
Newborn and Child Health campaign is being carried out in Akwa-Ibom State, it
is important to study the influence of trainingon health promoters’ performance
as regards health promotion (social mobilization and health education) for
mothers – expectant and nursing,while also performing an assessment of the
maternal, new born and child health training. Being an external attempt at
evaluating the influence of training on MNCH health promoters’ performance, the
findings may provide information to the authorities in charge of the MNCH
campaign in Akwa Ibom State from a different perspective as regards strength
and weaknesses in the training, their methods of performance evaluation and
above all the Maternal, Newborn and Child Health campaign.
1.3 Objective of the Study
The
general objective of this study is to assess the influence of training on the
performance of health promoters in maternal newborn and child health education
in Akwa Ibom State. The specific objectives are to:
1. identify the communication materials used in
the training for health promoters in the Akwa Ibom State maternal newborn and
child health campaign;
2. determine the adequacy of the environment used
for the training of health promoters in the Akwa Ibom State maternal, new born
and child health campaign;
3. find out the duration of the training for
health promoters in the Akwa Ibom state maternal new born and child health
campaign;
4. ascertain the level of the social mobilization
for mothers carried out by health promoters in Akwa Ibom State towards
influencing mothers’ health behavior;
5. find out the extent of Maternal, Newborn and
Child health education given to mothers by health promoters towards influencing
mothers’ health behaviours and
6. determine the level of health promoters’
influence on mothers’ health behaviours as perceived by the mothers.
1.4 Research Questions
The following are the research questions which guided the conduct of this
study.
1. Which communication materials are used in the
training of health promoters in the Akwa Ibom State maternal newborn and child
health campaign?
2. How adequate is the environment used for
training of health promoters in the Akwa Ibom State maternal newborn and child
health campaign?
3. What is the duration of the training for
health promoters in the Akwa Ibom State maternal newborn and child health
campaign?
4. What is the level of social mobilization
carried out by health promoters in the Akwa Ibom State for mothers towards
influencing mothers’ health behaviour?
5. To what extent is MNCH education given to
mothers by health promoters towards influencing their Health behaviours?
6. What is the level of health promoters’
influence on mothers’ health behaviours as perceived by the mothers?
1.5 Hypotheses
To be tested at a
preset 0.05 Level of Significance
H01: Social mobilization does not significantly influence
mothers’ health behaviour.
H02: Health education does not significantly influence
mothers’ health behaviour.
H03:Social mobilization and health education do not significantly
influence mothers’ health
behaviour.
1.6 Scope of the Study
This study focused on training and its influence on the promotion of
health and behavioral practice between health promoters (trainees) and mothers
in Akwa Ibom State as initiated by the maternal, newborn and child health
campaign. This study investigated the MNCH training – the environment and communication
materials used. Furthermore this study focused on health promotion from the
perspective of social mobilization and health education. This study measured
performance of health promoters using health behaviours, perception of social
mobilization and perception of health education of mothers registered at
primary health care facilities as proxies. In addition, the study was limited
to health promoters – specifically recipients of the 2016 MNCH training and
registered mothers (nursing or delivered) in Akwa Ibom. This study was carried
out between September and December 2016.
1.7 Significance of the Study
This
study is essential as it is coming just after the flag off of the Sustainable
Development Goals (SDGs) which have been re-engineered to focus on the failure
of the actualization of the of the MDGs. The results of the study would serve as
the actual evaluation of training for health promoters in Akwa Ibom State. This
study would reveal how MNCH trainings for health promoters are being carried
out. This study would further serve as the evaluation of the practical
direction of Akwa Ibom State maternal newborn and child health campaign towards
the reduction of maternal, new-born and child mortality. Being an external
attempt at evaluating the influence of training on health promoters’
performance, results can benefit state authorities in charge of the maternal
newborn and child health campaign in Akwa Ibom State in the conduct of health
promoters’ performance evaluation as well as the training, needs and challenges.
The major objective of the MNCH training activities since its inception is the
improvementof health workers’ and promoters performance, hence a reduction of
maternal and child mortality rates in Nigeria. However, a reduction in
maternal, infant and child mortality figures has not been significantly
achieved, so this work would inform policy makers about what needs to be done
in order to enhance health promoters’ trainings especially as regards
developing appropriate training communication materials, methods and equipment
for health promotion, in order to significantly reduce maternal, new-born and
child mortality rate in Akwa Ibom State. This study would also provide
information for further research towards improving maternal and child health
care, thus contributing to the already existing body of knowledge in training,
MNCH and health promotion practice.
1.8 Operational Definition of Terms
Communication Materials: These are MNCH materials developed
specifically to pass information to health promoters in order to develop and
enhance their ability to carry out health education in Akwa Ibom State MNCH campaign.
Mothers’ adoption or non-adoption of new health behaviour as suggested by
health promoters (an improvement in health promoters’ performance) will suggest
the adequacy of the training materials and the training.
Training: This is the determinant of health promoters’ performance. It is an
MNCH campaign activity specifically designed to build the capacity of Maternal,
New-born and Child Health promoters in carrying out health education and social
mobilization. Its effectiveness or in-effectiveness will be indicated by the
performance of health promoters in health education; measurable through
mothers’ perception and adoption of the health information.
Performance of Maternal Newborn and Child
Health Promoters: It is
the extent to which MNCH promoters influence an adjustment in mothers’ health
behaviour through health education as influenced or guided by MNCH training. Performance
is measurable through mothers’ perception ofhealth education, participation in
social mobilization and the final adoption of new health behaviours. It is also
an indicator of the effectiveness or ineffectiveness of MNCH training.
Health Behaviour: This is the perception of practices that are
carried out by women in respect of their health and that of their babies as
informed by the health promoters. It is the health promoters’ performance
indicator.
Health Education:It is the tool used by MNCH promoters
influence mothers’ health behaviours. It involves the communication of
information by health promoters to the mothers regarding hygiene, exclusive
breastfeeding, complimentary feeding, HIV prevention, family planning and the
need for immunization.
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