INFLUENCE OF TRAINING ON THE PERFORMANCE OF HEALTH PROMOTERS IN MATERNAL, NEWBORN AND CHILD HEALTH EDUCATION IN AKWA IBOM

CHAPTER ONE

INTRODUCTION

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.      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 improvement of 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 of health 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.