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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.
Keywords: Training, Health promotion, Health Education, Social Mobilization, Health
Word Count: 481
Title Page i
Table of Contents vi
List of Tables ix
List of Figures x
CHAPTER ONE: INTRODUCTION
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 9
2.1 Conceptual Model 9
2.2 Review of Relevant Concepts 10
2.2.1 Training and Health Promoters’ Performance 10
2.2.2 Health Promotion and Communication 12
2.2.3 Health Promotion Strategies 14
188.8.131.52 Social Mobilization 14
184.108.40.206 Health Education 15
2.2.4 Maternal, Newborn and Child Health Promotions 17
220.127.116.11 Immunization 17
18.104.22.168 Breastfeeding 18
22.214.171.124 Hygiene 20
2.2.3 Maternal Health 21
2.2.4 Newborn and Child Health 24
2.3 Theoretical framework 27
2.3.1 Trans-theoretical or Stages of Change Model 27
2.3.2 Social Penetration Theory 29
2.2.3 Goal Orientation Theory 31
2.4 Empirical Review 32
2.5 Summary 37
CHAPTER THREE: METHODOLOGY
3.0 Introduction 38
3.1 Research Design 38
3.2 Population 38
3.3 Sample size and sampling Technique 39
3.4 Research Instruments 43
3.4.1 Structured Questionnaire 43
3.4.2 Interview Guide 43
3.4.3 Focus Group Discussion Guide 43
3.5 Validity of Research Instrument 44
3.6 Reliability of Research Instrument 44
3.7 Administration of Research Instrument 44
3.8 Method of Data Analysis 45
CHAPTER FOUR: DATA ANALYSIS,RESULTS AND
DISCUSSION OF FINDINGS
4.0 Introduction 46
4.1 Presentation of Results 46
4.1.1 Presentation of Qualitative Results 46
126.96.36.199 Communication Materials 46
188.8.131.52 Adequacy of training environment 47
184.108.40.206 Duration of Training for Health Promoters 47
220.127.116.11 Social Mobilization carried out by Health Promoters 48
18.104.22.168 MNCH Education and Mothers’ Health Behaviour 49
4.1.2 Presentation of Quantitative Results 50
22.214.171.124 Interpretation of Quantitative Results 55
4.2 Test of Hypotheses 65
4.2.1 Decision Rule 65
4.3 Discussion of Findings 67
CHAPTER FIVE: SUMMARY, CONCLUSION AND
5.1 Summary 72
5.2 Conclusion 73
5.3 Recommendations 74
5.4 Suggestion for Further Studies 75
LIST OF TABLES
2.1 Key Maternal, Newborn and Child Health Indicators 21
3.1 List of Selected Local Governments, Ward, Health Facility
and Number of Registered Mothers 40
3.2 Proportion of the Number of Registered Mothers per Health Facility 42
3.3 Proportional Distribution of Registered Mothers’ Sample Size 42
4.1 Respondents Socio- Demographic features 50
4.2 Mothers who vaccinated their babies 53
4.3 Mothers who believed that Breastfeeding a baby is a good habit 54
4.4 Mothers who give hygiene a lot of attention 54
4.5 Level of Social Mobilization by Health Promoters in Akwa Ibom 55
4.6 Extent to which MNCH Education is given to mothers by Health Promoters 59
4.7 Level of Health Promoters Influence on Mothers’ Health Behaviours 62
4.8 Influence of Social Mobilization on Mothers’ Health Behaviours 65
4.9 Influence of Health Education on Mothers’ Health Behaviours 66
4.10 Influence of Health Education and Social Mobilization on
Mothers’ Health Behaviours 66
LIST OF FIGURES
2.1 Conceptual Model 9
4.1 Respondents’ Age Range 51
4.2 Respondents’ Marital Status 52
4.3 Respondents’ Household size 52
4.4 Respondents’ Number of Children 53
4.5 Mothers who had vaccinated their babies and mothers with
Positive perception of breastfeeding and hygiene 54
4.6 Level of Social Mobilization by Health Promoters in Akwa Ibom 58
4.7 Level of Health Promoters influence on Mothers’ Health Behaviours 61
1.1 Background 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 training on 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:
1.4 Research Questions
The following are the research questions which guided the conduct of this study.
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
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.