“It builds your confidence… you’ve done well”: Healthcare workers’ experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana

Background

Over the past 25 years, global newborn mortality rates have not decreased as dramatically as maternal and child mortality rates, despite an increase in skilled birth attendance and facility-based births¹. The majority of newborn deaths (75%) occur during the first week of life, and 25%‒45% occur within the first 24 hours². For the first time in history, intrapartum-related events are among the top three global causes of death of children under five years of age³.

In 2015, Ghana ranked 53rd out of 225 countries with the highest infant mortality rates, even though 73% of births occurred in facilities with skilled birth attendants⁴. Increasing the use of evidence-based interventions during labor and birth—infection prevention; monitoring the progress of labor with a partograph; and essential newborn care such as drying, provision of warmth, clean cord care, immediate initiation and exclusive breastfeeding, and resuscitation with bag and mask ventilation—could prevent many intrapartum stillbirths and newborn deaths in Ghana.

Improved effectiveness and scale of pre-service education and in-service capacity building for healthcare workers is necessary to implement the interventions to achieve better health outcomes. Recent reviews have highlighted substantial variation in the effectiveness of strategies to improve healthcare quality in low and middle income countries⁵, and found there is little consensus on what distinguishes myriad interventions to support and improve healthcare worker performance (i.e. supervision, mentoring, coaching, quality improvement), nor on optimal approaches to delivering such interventions in different settings^6,7. Evidence suggests that when used effectively, techniques such as frequent practice on anatomic models; simulation of the work environment; interactive discussion of case studies; problem-based learning; reminders; and the use of mobile media can bring about desired learning outcomes⁸. Educational techniques that rely on passive transfer of information, on the other hand, such as lecture and reading, are less effective^9,10.

Program description

In 2014, Jhpiego introduced a “low-dose, high-frequency” (LDHF) training approach, in tandem with an ongoing quality improvement program in 40 district and regional hospitals across the Central, Western, and Upper West regions of Ghana¹¹. The objective was to transform the attitudes, skills, and knowledge of healthcare workers providing labor, birth, and postpartum care, in an effort to reduce preventable deaths.

The LDHF approach emphasizes skills competency through simulation and case-based learning, and appropriate spacing of training sessions with brief content delivery. By training midwives and doctors together and establishing a culture of learning at the health facility level, the LDHF approach reduces the time healthcare workers must spend away from work in offsite trainings, potentially increases opportunities for hands-on training, and could increase the number of healthcare workers trained at each site.

The Ghana LDHF training package had two parts: (1) two 4-day low-dose training sessions in basic emergency obstetric and newborn care including newborn resuscitation (Box 1) and (2) frequent practice during and after the training (Figure 1). Experienced Ghana Health Service doctors and midwives were prepared as master mentors (MM) to provide the low-dose training to healthcare workers in facilities in their regions. At every facility, at least two healthcare workers were selected to become peer practice coordinators (PPCs) and were trained on the use of anatomic models and on coordinating high-frequency practice sessions to help build clinical proficiency among their colleagues. Facilitated by the PPCs, the healthcare workers practiced the skills they learned for one year during and after the low-dose trainings. In addition, all healthcare workers received mobile mentoring (mMentoring), which consisted of weekly SMS reminder messages and quiz questions on the topics covered in training. The PPCs received structured, weekly half-hour telephone calls from the master mentors, during which the mentors answered questions, provided guidance, and reinforced key messages. Healthcare workers, PPCs, and MMs received no additional incentive to attend trainings, engage in mentoring, or practice. Within one year of the initiation of LDHF, risks of intrapartum stillbirth and newborn mortality within 24 hours of birth reduced by over 50%¹².

Figure 1. Low-dose, high-frequency training approach for newborn survival.

This study sought to explore healthcare workers’ experiences with this approach to in-service training, and to understand the factors contributing to intervention effects. It was one component of a mixed-methods evaluation of the Bill and Melinda Gates Foundation-funded “Accelerating Newborn Survival in Ghana” project; intervention cost-effectiveness and impacts on risk of intrapartum stillbirth and early neonatal mortality are reported elsewhere^11,12.

Study design

In this cross-sectional qualitative study, we conducted focus group discussions (FGDs) and in-depth interviews (IDIs) at nine of the 40 health facilities included in the cluster-randomized trial to evaluate project impact¹¹. Each FGD included four to six healthcare workers who participated in the program, including doctors, midwives, and nurses providing labor, birth, and postnatal care. A total of 20 IDIs were held with PPCs and MMs. Data were collected in April 2016, at the end of the second year of the three-year LDHF program implementation. Interview guides are provided as Extended data¹³.

Sampling and study population

Study sample size was determined using qualitative criterion-based strategies, with the aim of capturing a range of perspectives reflecting the diversity of program participants. A purposive sampling technique was used to select one high-, one average-, and one low-performing health facility from each of the first three implementation waves of the LDHF program, based on the number of practice sessions held and the reduction in newborn mortality observed after the low-dose trainings. If a facility was in the top third of facilities for both indicators, they were considered high performing; facilities in the bottom third for both indicators were considered low performing. From within facilities eligible, we purposively sampled a range of large and small, urban and rural facilities to gather a variety of experiences. From within the sampled facilities, convenience sampling was used to select nine PPCs for IDIs. Nine master mentors were selected for IDIs based on convenience sampling, three from each region and two from the regional health management team. All healthcare workers who participated in the LDHF training and who were not PPCs or MMs were invited to participate in FGDs. PPCs were excluded from the FGDs to allow open dialogue about their role within the facility. All participants were over the age of 18, had participated in the implementation of the LDHF program, and provided written informed consent.

Recruitment

Study team members sent letters to the regional health management teams to inform them of the study purpose, methods, eligible participants, and proposed dates. The regional health management teams sent letters with the same information to managers at the selected facilities. Facility management then set up appointments for the IDIs and FGDs with selected staff at the facilities. Study team members made follow-up phone calls to facilities to confirm the dates for the FGDs. The study team contacted eligible MMs by phone, explained the purpose of the study and the methods, and invited them to participate.

Data collection

IDIs and FGDs were conducted in private rooms in the hospital maternity ward or in a conference room. All rooms afforded auditory privacy, and no non-participants were present. The study team explained the purpose, benefits, and risks of the study and obtained informed consent. Data were collected by two independent, qualitative researchers who had completed two days of training on the LDHF program and approach, informed consent and ethical principles, and qualitative methods and data collection tools. The researchers had no known prior relationship with the participants.

FGD and IDI guides were developed and pilot-tested in three hospitals outside the study regions where the LDHF training had also been conducted. IDIs lasted 40 to 60 minutes and FGDs lasted 70 to 90 minutes. All interviews and FGDs were conducted in English and audio-recorded. In each IDI or FGD, one researcher facilitated the discussion, while the other took notes. Following each session, both researchers wrote field notes on group discussion themes and other observations. Each day after data collection, the in-country principal investigator listened to the audio recordings and provided guidance to the researchers on areas they should probe further.

While the study team discussed the concept of saturation, data collectors completed the number of interviews and FGDs assigned, to ensure experiences of program participants at a range of large, small, urban and rural facilities were considered.

Data analysis

The researchers who conducted the IDIs and FGDs transcribed all of the audio recordings. Data analysis was guided by an objectivist epistemology¹⁴. Three other study team members were responsible for coding and analyzing the transcriptions, and a larger LDHF study team validated the findings. Responses were first grouped based on pre-defined codes. Deductive qualitative thematic content analysis methods were used to develop a preliminary coding scheme. Inductive methods were then used to identify emerging themes within each code. Themes and codes were reviewed and discussed throughout the analytic process, and refined or adapted as needed based on emergent information from the transcribed data. Data were analyzed by type of participant, then discussed and summarized, with differences between types of participants noted. Study team members recorded summaries of all codes individually, and then further summarized them following team discussion in order to incorporate the perspectives of all participants. Coding and analysis of themes was conducted using Atlas.ti Version 7.5 (Atlast.ti GmbH, Berlin, Germany, 2016).

Ethical approval

Ethical approval and oversight was provided by Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB# 5442), Baltimore, MD, USA, and the Ghana Health Service Ethics Review Committee (ERC# GHS-ERC-10/11/13) in Accra, Ghana. The study was nested within a cluster randomized trial registered in ClinicalTrials.gov (NCT03290924).

1. The LDHF Approach: “It builds you your confidence”

Participants acknowledged that the content of the training was not new but how the learning experience was designed and implemented was completely different from their past experiences.

Facility-based, team learning: “we are all there”

The majority of respondents noted benefits of the training being held within their own facility where all relevant colleagues could participate, democratizing the learning opportunity.

Healthcare workers could also balance the training with their routine work on the ward. MMs repeated sections of the training throughout the day and into the evening to ensure that all participants received training on all modules while they managed their normal duties. This reduced time away from their work and ensured that they could quickly return to the ward to attend to cases if needed. This also meant that participants with special needs (e.g. breastfeeding) could also participate. Both MMs and healthcare workers felt that the whole-team focus of the LDHF approach built a team ethos, making it easier to translate the learning to practice because everyone was trained in the same content areas and skills. This even extended to new staff or rotating students joined the facility.

The involvement of hospital management in the learning experience was critical. In some hospitals, managers recognized the value of the training approach and provided support during and after the training to encourage healthcare workers to participate. Participants shared examples of matrons and managers observing training and developing rosters to support healthcare workers to maintain their practice on models with positive effect on performance of healthcare workers. Participants acknowledged that without management staffs’ active participation and leadership, dedicating time to practice and introducing new procedures in the provision of clinical care would not be implemented.

Hands-on learning: “then we’ll do”

Respondents appreciated that the LDHF training approach was practical, unlike traditional theory-oriented training approaches, noting the use and benefit of birth and newborn simulators (i.e., MamaNatalie® and NeoNatalie™) during the training sessions. The skills-based approach focusing on competence of all team members, enabled them to practice and become confident in the lifesaving skills they needed on a regular basis and during emergencies.

During the on-site sessions MMs were able to address the needs of individual learners. For example, when facility staff performed a procedure incorrectly, the master mentors took time, one-on-one as necessary, to ensure that they were able to perform it successfully and confidently before the end of the training session.

Hands on practice with the models built confidence in the ability to use these lifesaving skills on real patients. Feeling confident in their skills was in of itself was also rewarding and motivating for participants.

MMs found that despite the approach yielding positive results with most participants, they still had participants who were resistant to the learning experience or struggled to achieve competence. MMs noted that they had to spend individual time with these participants and it often took much longer for them to achieve competence because they needed to first overcome the resistance to the new practices and then build their confidence to implement them.

It was evident that how MMs interacted with learners during learning sessions and demonstration on models was incredibly important. If they were supportive and managed mistakes constructively it facilitated learning and encouraged healthcare workers to learn and practice new skills. However, if MMs embarrassed the learners, particularly in front of their peers, this was demotivating, undermined confidence and in some cases, learners excluded themselves.

Some of the MMs and stakeholders shared that although the models were effective learning tools, only practicing on the models was limiting; they described having support while. providing direct client care as an important “final step”. Healthcare workers also noted that both time and space to were constraints to maintaining practice on the models. MMs noted that this varied among facilities, resulting in some healthcare workers being able to practice more than others. However, across all facilities, healthcare workers noted that over time the frequency of practice sessions decreased.

mMentoring: “it reminds you”, “they call me”

mMentoring included primarily SMS reminders and phone calls between mentors and healthcare workers. The aim of this was to provide reminders of key content covered in the training and support communication between MMs and healthcare workers. Respondents valued receiving SMS messages and quiz questions that commenced after the first learning session. They noted that the SMS messages reinforced content learned during the training sessions. The liked being able to refer to these key messages on their phones not only to remember what they learned and prompt new learning but also used as a reference guide when providing care in labor and delivery or even stimulated group discussion.

Despite this benefit, the SMS and quizzes proved difficult for some participants and became a significant area of frustration. They shared examples of challenges with this component including difficulty interacting with the automated program, inconsistency of the messages, challenges with responding to the quiz questions, cost of responding to an SMS; all contributing to some participants deciding not to participate in the SMS and quiz component of LDHF.

The purpose of the phone calls were to enable MMs to virtually follow up with each facility after the onsite learning sessions and to encourage them to continue their practice sessions and to provide an opportunity for them to talk through any issues that they were having and to hold them accountable for doing the things that they agreed to. Mentors also provided their telephone numbers to staff and encouraged them to call if they had questions.

Despite the positive feedback from all of the participants on the mMentoring component, some voiced concerns that mMentoring on its own was not sufficient for post-training follow-up and implementation support. A few of the MMs noted that they found the calls to facilities difficult to maintain. Staff would not answer their calls or did not feel that they were being honest. MMs recommended in-person mentoring for a number of reasons, in particular, to identify discrepancies between what is reported and what is actually done, and to provide direct, hands on mentoring support to healthcare workers to address gaps and solve problems. They suggested that an integrated approach including both in-person and mMentoring would be stronger.

2. Enabling implementation: “you've done well”

As participants shared and described their experiences with LDHF training they also articulated some of the factors that they felt supported implementation of what was learned during the onsite learning sessions.

Mentorship: “together, we can solve it”

MMs were carefully selected from each region by their regional directors. They were respected, competent and active healthcare workers themselves. The MMs themselves saw their role as being more than a traditional trainer who was responsible for imparting knowledge.

They felt that they were firstly role models for healthcare workers and they had a joint vision to improve care and reduce maternal and newborn deaths. They encouraged healthcare workers to share that vision for making a difference. A key element of this was advocacy to ensure that this was a priority for management and healthcare workers alike.

MMs initiated their relationships with teams of healthcare workers at facilities by leading the learning sessions, and maintained these relationships with teams over the next twelve months, primarily through mMentoring calls. Mentors described that a key part of their responsibility in this ongoing relationship was to provide support to health workers. This support was focused on encouraging teams to keep implementing what they had learned and to continue their practice on models. Some of the healthcare workers formed informal messaging groups with their MMs (i.e. established through WhatsApp^TM messaging application) and these groups provided the platform and opportunity to solve problems and share experiences with each other. These interactions were encouraging and reinforced both learning and application of learning in patient care.

The quality of the relationship between the MM and the healthcare workers appeared to be an important aspect of the ability to provide support. If healthcare workers felt comfortable in their relationship with a MM, they would call and request assistance or discuss the problem.

During these phone calls, MMs appeared to actively try to identify any problems that the team was facing and then they tried to assist teams to solve these problems. In many cases this was barriers to implementing new practices and problems that teams were encountering. Teams were encouraged to follow up request assistance from the MMs. Health care workers also provided examples of MMs directly helping teams solve problems. For example, one team worked with the Quality Improvement Team to address a commodity supply issue while another provided an example of improving data accuracy. Problem solving appeared to be collaborative, team-based and solution oriented.

Through their ongoing supportive relationship MMs were also holding teams accountable for implementing what they had learned and what they had agreed to implement or change in their facility. Again, involvement of management was important. This strengthened the feeling of accountability. Participants noted discussing health facility results and considering what was contributing to improvements or declines and then submitting them to management for review.

Motivating achievements: “there’ve been changes”

Another enabling factor that both MMs and healthcare workers described was motivation stemming from the results that they achieved. MMs described a sense of personal achievement that they got from their work. They were proud of the healthcare workers that they had worked with and appreciated the improvement that they had not only witnessed, but been part of. The immense satisfaction together with acknowledgement and appreciation of their role was a critical motivator to continue in this role. They also acknowledged that they had grown both personally and professionally and developed through the experience.

Healthcare workers reflected with real pride on their improved confidence and ability to provide lifesaving care. They shared examples of difficult cases and reflected on their ability to manage such cases before and after the LDHF approach was introduced. They also shared examples where they felt confident to stand up to other members of the team and provide care in the way that they thought was needed. Midwives in particular felt that a direct effect of their improved confidence and management was that fewer women needed to be referred to higher-level facilities or required assistance from doctors. They were able to manage more complicated cases independently as a result of their skills.

Both MMs and healthcare workers noted a significant change in the way that care was provided and how women and their families were treated. The training included a component of “respectful maternity care” and participants shared that this concept was new for them but in practice, it has made a big difference to their clients how their facility is perceived in the community. Respectful maternity care included giving clients and their companions the opportunity to understand and make decisions about the procedures performed during labor, birth, and the postnatal periods, such as examinations being performed and the position in which they prefer to give birth. As a result, clients were more cooperative and appreciative of the care they received, and even referred friends to the facility to give birth.

For participants, the most motivating of their achievements was that as a direct result of their improved management, confidence and skills—more mothers and babies were getting the care that they needed, being referred less and having better outcomes. Nearly all participants felt that there was a reduction in maternal and newborn mortality in their facilities because of the improved care that women were receiving. There was a feeling of ownership, purpose and pride that their improved skills and practice was having this tangible impact.

Underlying data

Qualitative data files may contain text that directly or indirectly identifies study participants. Data can be made available for further analysis upon reasonable request and signature of a formal data sharing and use agreement, provided research objectives are aligned with original study aims. Requests may be submitted to IRBHelp@jhpiego.org.

Extended data

Figshare: Accelerating Newborn Survival in Ghana_ Qualitative Data Collection Tools. https://doi.org/10.6084/m9.figshare.8150678.v1¹³.

Extended data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).