This study was conducted in November 2011, in the Iganga–Mayuge Health Demographic Surveillance Site (HDSS), located in two eastern Uganda districts of Iganga and Mayuge, approximately 120 kilometres east of Kampala, the capital city of Uganda. The HDSS covers a population of 74 894 people and is mainly rural. 10 863 are children under 5 years and 17 782 are women of reproductive age. The people predominantly practise subsistence farming among other occupations like business, market vendor and professional jobs (HDSS 2011). There are five health facilities that provide maternity services, and 68% of deliveries occur at health facilities, of which 71% are attended by skilled health workers (UBOS 2011). The NMR is estimated at 30 deaths per 1000 live births (HDSS 2011).
Background on UNEST study
Sixty-one literate CHWs were selected and trained for 5 days between June and July 2009 (Waiswa et al. 2012). The CHWs were trained in groups of 20 together with their supervisors (health workers), to enable them understand the CHWs' training scope and also get acquainted with CHWs. The methods of training included: role-plays using job aids, questions and answers, group discussions followed by plenary presentations, demonstrations and feedback sessions by facilitators. The CHWs' roles during pregnancy and after delivery were emphasised, including health education, screening for danger signs (Table 1) and counselling for referral. Other topics covered are shown in Panel 1. At the commissioning ceremony, CHWs were presented with a certificate of attendance, job aids, a bag and a T-shirt-labelled UNEST for identification in their respective villages.
Table 1. List of newborn danger signs, communication and referral form attributes
|New born danger signsa|| |
Rapid breathing in a calm child
Lack of body movement when stimulated
Red umbilicus or cord with pus
More than 10 skin pustule
Not breast feeding or drinking
bSmall baby born < 37 weeks of gestation (preterm baby)
|Required communication attributes|| |
Clear explanation of purpose of the visit
Request to examine the newborn
Examination of the newborn
Informing the mother that the newborn needs to be referred to the health facility
Clear explanation for the referral
Mentioning clearly place to go to for referral care
Mentioning clearly when to go for referral care
Clearly explain to the mother that they need to keep the newborn warm and continue breastfeeding while being taken for referral care.
|Pre-designed referral attributes on referral form that were completed|| |
Name of referring community health worker
Panel 1. Uganda Newborn Survival Study (UNEST) and CHW training package
Description of Uganda Newborn Survival Study IS-RCTN50321130
To test an integrated maternal–newborn care package that links community and facility care and evaluate its effect on maternal and neonatal outcomes in Iganga and Mayuge districts (Waiswa 2010).
A cluster randomised trial in 32 control and 31 intervention villages, located in a demographic surveillance site with about 74 894 people in eastern Uganda.
- Trained health workers and provided supplies and equipment to strengthen maternal and newborn care services in health facilities
- Trained 61 CHWs to link communities and health facilities by:
- CHWs making two home visits to pregnant mothers and three visits during the first week after birth
- CHWs referring mothers and newborns found with danger signs and those born outside facilities for immunisation and postnatal care.
The CHWs were supervised in three ways: i) monthly meetings with their supervisors at the health facility, ii) directly observed supervision (DOS) for the first 6 months of the intervention, where the supervisor used a standard checklist to observe how a CHW conducted antenatal and postnatal home visits uninterrupted. Thereafter, the supervisor corrected mistakes and reinforced the knowledge and skills of the CHW, and iii) quarterly meetings comprising of health workers, CHWs, DHT and UNEST members, and integrated with refresher trainings.
Content of the training provided to CHWs regarding newborn care included
- Birth preparedness
- Cord care
- Thermal care
- Breastfeeding and initiation
- Kangaroo mother care
- Newborn danger signs
- Newborn referral
- Community mobilisation skills
The CHWs were supervised during monthly meetings with their supervisors, by directly observed supervision (DOS) and quarterly meetings, all characterised by reinforcing knowledge and skills (Panel 1).
CHWs' competence to identify and refer sick newborns was determined using tools adapted from training materials used in UNEST study. Competence was defined as having sufficient knowledge and ability to recognise sick newborns at a pre-defined pass mark, similar to a study that evaluated health workers' competence in maternal and newborn care in Pakistan (Ariff et al. 2010). We evaluated 3 attributes of the CHWs' competence: (a) knowledge about newborn danger signs, (b) ability to recognise newborn danger signs and (c) ability to effectively talk to mothers about newborn danger signs and counsel them to seek care from health facilities.
A structured questionnaire was used to evaluate CHWs' level of knowledge about newborn danger signs by asking CHWs to name 5 newborn danger signs they knew (unprompted), and to indicate whether a named sign was a newborn danger sign or not by answering true or false (prompted). There were a total of 11 danger signs for the prompted questions (Table 1), as outlined in Uganda's National Newborn Standards (MOH 2010) and the newborn continuum of care (WHO 2006; Kerber et al. 2007). One score was awarded for each correct danger sign mentioned. CHWs' knowledge was adequate if they mentioned five newborn danger signs (unprompted), and if they correctly recognised all the 11 danger signs read to them (prompted). Thus, the knowledge component was allocated a minimum score of zero and a maximum of 16 points.
The structured questionnaire was also used to collect the CHWs' background characteristics including age, sex, marital status, education status, ethnicity, occupation, number of newborns referred in the last 25 months prior to the study, period of working as CHW for UNEST study and past experience of working as CHWs prior to participating in UNEST.
To assess CHWs' ability to identify newborn danger signs, four case-vignettes were used. Case-vignettes have been used to evaluate skills of primary health workers in case management of serious illness among young infants (Gouws et al. 2005). Our case-vignettes were developed using sick newborn clinical notes from Iganga district hospital by the study investigators together with a consultant paediatrician who is a team member of UNEST. They were reviewed by another paediatrician independently of this study. Consensus was reached that three case-vignettes depicted sick newborns and one depicted a healthy newborn. The four case-vignettes used in this study are described in Panel 2. A total of 11 newborn danger signs were embedded in the four case-vignettes.
The case-vignettes were translated into Lusoga, the local language most commonly used in the study area, by a language specialist based at the HDSS. Trained interviewers (a public health specialist and three nursing officers) read out each case-vignette to a CHW at least three times and complemented it with pictures showing newborn-specific danger signs to ensure that the CHW understood the newborn in description.
Panel 2. Case-vignettes used in the assessment of skills of CHWs to identify newborn danger signs
Case-vignette 1: During your work as CHW, you visit a home with a 3-day-old baby boy. The mother seems worried because the baby has been persistently crying and has failed to suckle in the last 24 h. When you check on the baby you find that the cord is still attached but with a smelly fluid oozing out and parts of the baby's body are covered with pustules.
Case-vignette 2: A father of a newborn in your work area comes and reports to you that his 3-week-old baby is not well. You quickly go to check on the baby and you are told that the baby cries a lot but keeps quiet after suckling. The mother complains that the baby wants to suckle all the time and feeds over 10 times in a day. The mother is very worried and concerned about the condition of the baby (no danger signs in this scenario, baby is not sick).
Case-vignette 3: As part of your responsibilities you go out to visit one of the families with a newborn. You are told that the baby is well apart from feeling very hot and also pushing its head backwards. When you ask to be shown the baby you find that the baby's neck and limbs are difficult to move but keeps jerking. The baby also looks very pale and is small, weighing about two kilograms.
Case-vignette 4: You receive the news that one of the mothers in your work area delivered in the previous night. You prepare and go to visit the family of the newborn. You request to see the baby. When you hold it and look at the baby' eyes, they are closed. The baby has no power in all the limbs, has difficulty in breathing and feels cold. However, the mother says that she had no problem during delivery and the baby is well.
For evaluation, a CHW was asked to point out whether the newborn in the given case-vignette had any danger sign or not, specify the danger sign(s), if any, in each of the 4 case-vignettes and actions they would take in each scenario. Each correct answer was awarded one point and none for an incorrect one. The minimum score for the four case-vignettes was zero, and the maximum was 11 points.
The CHWs' effectiveness in communicating to mothers to seek health care for their sick newborns was evaluated using role-plays. Role-plays have been used in assessing communication skills among nurses working in an intensive care unit in New York (Krimshtein et al. 2011). Two aspects of effective communication by CHWs were assessed using tools adapted from UNEST supervision checklists: observing the CHW's communication skills to the mother in the role-play, and the quality of the completed pre-designed referral form. A consenting mother with a healthy newborn was identified from the study community and coached to participate in the role-play as if the newborn had fever and the baby's cord was smelly with pus. Each CHW was instructed to assume that the description of the condition of the newborn by the mother was correct. Using a pre-designed checklist, the interviewers critically observed and took note of every CHW's action as he or she communicated with the mother. Ten communication aspects (Table 1) were assessed. Each of these aspects was scored one point if done and none if not done. Every CHW was expected to perform all the 10 communication attributes. Regarding referral, the CHW was expected to request for a referral form, and complete it with all the eight necessary details as listed in Table 1. The pre-designed referral form was provided by the observer on request by the CHW in case (s) he found it necessary to use it after interacting with mother. Each item filled correctly was scored one point and none if left blank. Thus, the communication component was allocated a minimum score of zero and a maximum score of 18 points.
Data were entered in Epi-Data software and exported to STATA version 10 for analysis. Regarding knowledge and ability to identify newborn danger signs from the case-vignettes, proportions were calculated and reported for the attributes scored as outlined above. The range and median scores attained by the CHWs were also computed.
For effective communication of CHWs, we calculated the proportion of CHWs who were able to display the required communication attributes as listed in Table 1, during the role-plays, and the proportion of CHWs who correctly completed the referral form with all the eight attributes listed in Table 1.
For each component, we computed a total score for every participant and the proportion of CHWs who attained the pass mark. Because there are no national references, for each component an arbitrary pre-defined pass mark was set. For knowledge, it was 100%, because this was considered to be a relatively easy task of mentioning only five newborn danger signs of the eleven. For skill and communication, it was set at 90% because same attributes were regularly assessed during supervision.
Because of the small number of CHWs involved in this study, the summary measures used were medians and interquartile range (IQR), and statistical comparisons between groups were made using non-parametric test like the Wilcoxon rank-sum (Mann–Whitney) test.