Effectiveness of Participatory Community Health Actors Intervention on Improving Health Facility Delivery in Jimma Zone, Ethiopia: A Cluster Randomized Controlled Trial

Abstract

Introduction: In developing countries including Ethiopia, poor health status of citizens is one of the factors behind the low level of economic development. Ethiopia is working greatly with great progresses in maternal, neonatal and child health during the Millennium Development Goal period (1990-2015), mainly credited to the innovative community based program of health extension package into rural areas. However, successes were not grasped at all regions and urban-rural settings, as a result, the maternal health care utilization has remained low; especially health facility childbirth is very low. To close this gap, the Ethiopian government proposes multiple strategies including community based intervention at various levels including individual, family and community. However, there is a dearth of evidence on the effectiveness of community health actors through participatory community based intervention approach on improving health facility childbirth. Therefore, the aim of this study was to assess factors affecting health facility delivery and to evaluate the effects of community based participatory community health actor’s intervention in improving the utilization of health facility delivery over the study periods. Method: Various participatory training support, educational materials, and communication activities were implemented from May 2017 to June 2019 in three districts of Jimma zone to promote maternal and child health services. As this study also embedded under the main project, we employed both qualitative and quantitative studies enrolling different groups of participants based on different research questions. Accordingly, the study first tried to explore the actual roles and contribution of possible community health actors and credible sources of maternal health services through qualitative study that was conducted in May 2016. Further, to assess factors affecting health facility delivery including social support as main factor, and evaluate the effectiveness of participatory community health actors’ intervention on improving health facility childbirth, we used a community based cluster-randomized control trial in Jimma zone from 16 randomly selected health centers including a total of 5014 women (2394 in control and 2620 in intervention arms) were enrolled during baseline and endline phases of the study. So health facility delivery was compared at endline between intervention and control groups using a generalized linear mixed model analysis. The final differences during baseline and endline were constrained by including fixed effects for period and intervention by period. Data were analyzed using the SPSS version 20 software. Various regression modeling techniques including xiii multivariate general linear modeling were performed. Odds ratios with 95% confidence intervals and alpha of 0.05 were used to report comparisons between intervention and control groups. Result: The findings of qualitative study showed the most commonly cited roles identified by all participants were promotion of health care services, provision of continuous support during pregnancy, labour and post-natal care (PNC), and working as a link between communities and the health system. HEWs, WDA and religious leaders were identified as credible sources and best in passing different knowledge on to mothers, family members and members of the community during community meetings, women’s association meetings, antenatal outreach sessions, and coffee ceremony on topics like use of maternal and child health (MCH) services like anti-matal care (ANC) services, health facility delivery and related cares. According to the quantitative study (research question 2) result showed that despite the huge effort made to provide maternal health services free of charge, utilization remains low and only 46.9% of women delivered at health facility in their last pregnancy. Average travel time from closest health facility (AOR: 1.51, 95% CI 1.21 to 2.90), mean perception score of health facility use (AOR: 1.83, 95% CI 1.44 to 2.33), involvement in final decision to identify their place of childbirth (AOR: 2.12, 95% CI 1.73 to 2.58) had significantly higher odds of health facility childbirth. From social support variables, women who perceived there were family members and husband to help them during childbirth (AOR: 3.62, 95% CI 2.74 to 4.79), women who received continuous support (AOR: 1.97, 95% CI 1.20 to 3.23), women with companions for facility visits (AOR: 1.63, 95% CI 1.34 to 2.00) and women who received support from friends (AOR: 1.62, 95% CI 1.16 to 3.23) had significantly higher odds of health facility childbirth. Data from the final evaluation study (research question 3) were analyzed using intention-to-treat, and the result showed that in the unadjusted and adjusted analysis, women in the intervention group were 2 times and 12 times more likely to use health facility delivery than women in the control group OR 2.12; 95 CI 1.20-4.44), and (AOR 12.83; 95 CI 2.10-82.70); respectively; women in the intervention group were 2 times more likely to involve in deciding the final place of childbirth than women in the control group (OR =2.72; 95% CI 1.37–5.40). As of maternal social support outcomes, the women reported receiving different types of supports from three different sources, including family members, close friends and community health actors (CHAs). The result showed that from close ties the women received tangible supports (86.2% for intervention and 70% for control), emotional supports (80.8% for intervention and 64% for control), and xiv accompaniment supports (62% for intervention and 46% for control) and these received supports were increased across all groups between baseline and endline. Therefore, generalized linear mixed model analysis showed that significant increase were observed in intervention groups for tangible support (OR= 26.8, 95%CI: 5.4-113.0), emotional support (OR = 11.3, 95%CI: 6.0 to 23.0), accompaniment, (OR= 16.3, 95%CI: 5.0 to54.5). Further, a mean differences (MD) in received continuous advice and supports from CHAs (MD=3.8; 95 CI: 3.71 to 3.81; effect size (ES)=41%), in received continuous advice from close ties (MD=4.9; 95% CI: 4.85 to 5.00; ES=13%), density of ties (MD=14.3; 95 CI: 14.2 to 14.2; ES=8%), perception on benefits of MCH use (MD=3.8; 95 CI: 3.71 to 3.83; ES=93%), and attitude towards health facility delivery (MD=7.3; 95 CI: 7.2 to 7.5; ES=6%), were significant favoring the intervention group. Conclusion and recommendation: As the qualitative studies and baseline survey confirmed community health actors (HEWs, WDA, religious leaders) were identified as epicenter in providing different MCH promotion activities that can be positive to use for community based intervention in improving MCH cares including ANC, childbirth and early PNC services. Accordingly, given all the limitations the findings from our interventional study suggested that participatory CHAs intervention appears to be more effective not only in improving health facility childbirth but also in enhancing various social supports and creating positive attitudes and making shared decisions in using health facility delivery. Thus maternal health promotion programs need to leverage CHAs including families and faith-based organizations in addition to health professionals in disseminating information in relation to MCH use, particularly health facility delivery in rural settings. Future research may compensate for the limitations of the current study by conducting a process evaluation along with outcome evaluation to ensure that the intervention is delivered and implemented as planned to indicate the fidelity of the implementation.