Increasing client participation in family planning consultations: Smart Patient coaching in Indonesia

In Indonesia, paternalistic models of health care, social distance between clients and service providers, and cultural norms discourage family planning clients from playing an active role in consultations. This report discusses the interventions needed to encourage clients to communicate more openly and more vigorously with providers. The study confirmed that educational interventions directed to family planning clients can help them become effective partners in their own care, assuming they meet with receptive providers. Communication interventions like Smart Patient complement and reinforce provider interpersonal communication and counseling training by giving clients the confidence and the skills to take advantage of increased opportunities for participation. Together, client and provider interventions can improve the quality of the client–provider interaction

Factors Predicting Ethiopian Anesthetists' Intention to Leave Their Job

BACKGROUND: Ethiopia has rapidly expanded training programs for associate clinician anesthetists in order to address shortages of anesthesia providers. However, retaining them in the public health sector has proven challenging. This study aimed to determine anesthetists' intentions to leave their jobs and identify factors that predict turnover intentions. METHODS: A nationally representative, cross-sectional survey of 251 anesthetists working in public-sector hospitals in Ethiopia was conducted in 2014. Respondents were asked whether they planned to leave the job in the next year and what factors they considered important when making decisions to quit. Bivariate and multivariable logistic regressions were conducted to investigate 16 potential predictors of turnover intentions, including personal and facility characteristics as well as decision-making factors. RESULTS: Almost half (n = 120; 47.8%) of anesthetists planned to leave their jobs in the next year, and turnover intentions peaked among those with 2-5 years of experience. Turnover intentions were not associated with the compulsory service obligation. Anesthetists rated salary and opportunities for professional development as the most important factors in decisions to quit. Five predictors of turnover intentions were significant in the multivariable model: younger age, working at a district rather than regional or referral hospital, the perceived importance of living conditions, opportunities for professional development, and conditions at the workplace. CONCLUSIONS: Human resources strategies focused on improving living conditions for anesthetists and expanding professional development opportunities may increase retention. Special attention should be focused on younger anesthetists and those posted at district hospitals

Evaluation of a quality improvement intervention to prevent mother-to-child transmission of HIV (PMTCT) at Zambia defence force facilities

BACKGROUND: The Zambian Defence Force (ZDF) is working to improve the quality of services to prevent mother-to-child transmission of HIV (PMTCT) at its health facilities. This study evaluates the impact of an intervention that included provider training, supportive supervision, detailed performance standards, repeated assessments of service quality, and task shifting of group education to lay workers. METHODS: Four ZDF facilities implementing the intervention were matched with four comparison sites. Assessors visited the sites before and after the intervention and completed checklists while observing 387 antenatal care (ANC) consultations and 41 group education sessions. A checklist was used to observe facilities’ infrastructure and support systems. Bivariate and multivariate analyses were conducted of findings on provider performance during consultations. RESULTS: Among 137 women observed during their initial ANC visit, 52% came during the first 20 weeks of pregnancy, but 19% waited until the 28(th) week or later. Overall scores for providers’ PMTCT skills rose from 58% at baseline to 73% at endline (p=0.003) at intervention sites, but remained stable at 52% at comparison sites. Especially large gains were seen at intervention sites in family planning counseling (34% to 75%, p=0.026), HIV testing during return visits (13% to 48%, p=0.034), and HIV/AIDS management during visits that did not include an HIV test (1% to 34%, p=0.004). Overall scores for providers’ ANC skills rose from 67% to 74% at intervention sites, but declined from 65% to 59% at comparison sites; neither change was significant in the multivariate analysis. Overall scores for group education rose from 87% to 91% at intervention sites and declined from 78% to 57% at comparison sites. The overall facility readiness score rose from 73% to 88% at intervention sites and from 75% to 82% at comparison sites. CONCLUSIONS: These findings are relevant to civilian as well as military health systems in Zambia because the two are closely coordinated. Lessons learned include: the ability of detailed performance standards to draw attention to and strengthen areas of weakness; the benefits of training lay workers to take over non-clinical PMTCT tasks; and the need to encourage pregnant women to seek ANC early

Identifying gaps in the practices of rural health extension workers in Ethiopia:A task analysis study

Background: Health extension workers (HEWs) are the frontline health workers for Ethiopia's primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs' pre-service education and practices. The aim of this study was to identify gaps in HEWs' practices and recommend changes in their training and scope of practice. Methods: A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared. Results: A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%-57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7-97.2%) perceived themselves as competent and proficient in performing tasks in all program areas. Conclusion: HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs' scope of practice, update pre-service education curricula and prioritize in-service training modules

Women's Experience of Facility-Based Childbirth Care and Receipt of an Early Postnatal Check for Herself and Her Newborn in Northwestern Tanzania

Negative experiences of care may act as a deterrent to current and/or future utilization of facility-based health services. To examine the situation in Tanzania, we conducted a sub-analysis of a cross-sectional household survey conducted in April 2016 in the Mara and Kagera regions of Tanzania. The sample included 732 women aged 15-49 years who had given birth in a health facility during the previous two years. Log binomial regression models were used to investigate the association between women's experiences of care during childbirth and the receipt of early postnatal checks before discharge. Overall, 73.1% of women reported disrespect and abuse, 60.1% were offered a birth companion, 29.1% had a choice of birth position, and 85.5% rated facility cleanliness as good. About half of mothers (46.3%) and newborns (51.4%) received early postnatal checks before discharge. Early postnatal checks for both mothers and newborns were associated with no disrespect and abuse (RR: 1.23 and 1.14, respectively) and facility cleanliness (RR: 1.29 and 1.54, respectively). Early postnatal checks for mothers were also associated with choice of birth position (RR: 1.18). The results suggest that a missed opportunity in providing an early postnatal check is an indication of poor quality of the continuum of care for mothers and newborns. Improved quality of care at one stage can predict better care in subsequent stages

Increasing patient participation in reproductive health consultations: An evaluation of Smart Patient coaching in Indonesia

Paternalistic models of health care, social distance between patients and providers, and cultural norms discourage patients from playing an active role in health consultations. This study tested whether individual coaching can give family planning patients the confidence and communication skills to talk more openly and more vigorously with providers. Educators met with 384 Indonesian women in clinic waiting rooms and coached them on asking questions, expressing concerns, and seeking clarification. An analysis of audiotaped consultations found that patients who received coaching articulated significantly more questions and concerns than others. Coaching narrowed differentials in active communication by patient type, age, and assertiveness, but it widened differentials by patient education and socioeconomic class. The discontinuation rate at 8 months was lower in the intervention than the control condition, but the difference was only marginally significant