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Afulani PA, Getahun M, Ongeri L, Aborigo R, Kinyua J, Ogolla BA, Okiring J, Moro A, Oluoch I, Dalaba M, Odiase O, Nutor J, Mendes WB, Walker D, Neilands TB. A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol. RESEARCH SQUARE 2024:rs.3.rs-4344678. [PMID: 38766153 PMCID: PMC11100884 DOI: 10.21203/rs.3.rs-4344678/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities. Methods The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness. Discussion This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.
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Afulani PA, Getahun M, Okiring J, Ogolla BA, Oboke EN, Kinyua J, Oluoch I, Odiase O, Ochiel D, Mendes WB, Ongeri L. Mixed methods evaluation of the Caring for Providers to Improve Patient Experience intervention. Int J Gynaecol Obstet 2024; 165:487-506. [PMID: 38146777 PMCID: PMC11021171 DOI: 10.1002/ijgo.15301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE To assess the impact of the Caring for Providers to Improve Patient Experience (CPIPE) intervention, which sought to improve person-centered maternal care (PCMC) by addressing two key drivers: provider stress and bias. METHODS CPIPE was successfully piloted over 6 months in two health facilities in Migori County, Kenya, in 2022. The evaluation employed a mixed-methods pretest-posttest nonequivalent control group design. Data are from surveys with 80 providers (40 intervention, 40 control) at baseline and endline and in-depth interviews with 20 intervention providers. We conducted bivariate, multivariate, and difference-in-difference analysis of quantitative data and thematic analysis of qualitative data. RESULTS In the intervention group, average knowledge scores increased from 7.8 (SD = 2.4) at baseline to 9.5 (standard deviation [SD] = 1.8) at endline for stress (P = 0.001) and from 8.9 (SD = 1.9) to 10.7 (SD = 1.7) for bias (P = 0.001). In addition, perceived stress scores decreased from 20.9 (SD = 3.9) to 18.6 (SD = 5.3) (P = 0.019) and burnout from 3.6 (SD = 1.0) to 3.0 (SD = 1.0) (P = 0.001), with no significant change in the control group. Qualitative data indicated that CPIPE had an impact at multiple levels. At the individual level, it improved provider knowledge, skills, self-efficacy, attitudes, behaviors, and experiences. At the interpersonal level, it improved provider-provider and patient-provider relationships, leading to a supportive work environment and improved PCMC. At the institutional level, it created a system of accountability for providing PCMC and nondiscriminatory care, and collective action and advocacy to address sources of stress. CONCLUSION CPIPE impacted multiple outcomes in the theory of change, leading to improvements in both provider and patient experience, including for the most vulnerable patients. These findings will contribute to global efforts to prevent burnout and promote PCMC and equity.
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Affiliation(s)
- Patience A. Afulani
- Epidemiology and Biostatistics Department, University of California, San Francisco, USA
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | | | - Osamuedeme Odiase
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Dan Ochiel
- County Health Directorate, Migori, Kenya
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Alelign YA, Melesse MF, Beka E, Alemu AA, Ejigu Meskele N, Asres CG. Person-centered maternity care during childbirth and associated factors among mothers who gave birth at public health institutions of Debre Markos town, Northwest Ethiopia, 2022: A cross-sectional study. SAGE Open Med 2024; 12:20503121231225352. [PMID: 38249947 PMCID: PMC10798133 DOI: 10.1177/20503121231225352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Background Person-centered maternity care is a crucial scheme for a positive childbirth experience. It enhances facility-based delivery, improves patient-provider communication, and increases women's satisfaction. However, there is limited evidence on the magnitude of person-centered care and certain variables were missed in Ethiopia. Therefore, this study assessed the magnitude of person-centered maternity care during childbirth and associated factors at health institutions of Debre Markos town, Ethiopia. Methods Institution-based cross-sectional study was conducted at public health institutions of Debre Markos town. Participants were enrolled using systematic random sampling technique. Data were collected through face-to-face exit interviews, cleaned, coded, and entered into Epi-Data version 3.1 then exported to SPSS version 25 for analysis. After generating simple linear regression analysis, variables with p-value ⩽ 0.25 were fitted into multivariable linear regression model and p-value < 0.05 was declared statistically significant with 95% CI for β. Finally, study findings were presented using texts, tables, and figures. Results In this study, 380 women participated, with a response rate of 98.19%. The respondent's mean person-centered maternity care score was 56.83 with 95% CI: (55.83, 57.83). Mean score for sub-scale was 15.08 for dignity and respect, 14.42 for communication and autonomy, and 27.33 for supportive care. Commencing antenatal care during third trimester (β = -4.86, 95% CI: -8.22, -1.49), caesarean delivery (β = -5.78, 95% CI: -7.68, -3.87), college and above educational level of women (β = 3.75, 95% CI: 1.11, 6.39), being multiparous (β = 3.69, 95% CI: 1.85, 5.55), and health center delivery (β = 6.59, 95% CI: 4.17, 9.02) were factors significantly associated with person-centered maternity care. Conclusion This study showed person-centered maternity care was low compared with World Health Organization standards. This informs local policymakers, district health offices, institutional healthcare administrators, and healthcare professionals of the discrepancies in achieving international standards of quality care.
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Affiliation(s)
- Yaregal Admasu Alelign
- Department of Midwifery, School of Health Sciences, Madda Walabu University, Bale Robe, Ethiopia
| | - Misganaw Fikrie Melesse
- Department of Midwifery, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Endihnew Beka
- Department of Midwifery, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Addisu Alehegn Alemu
- Department of Midwifery, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
| | - Neway Ejigu Meskele
- Department of Midwifery, School of Health Sciences, Madda Walabu University, Bale Robe, Ethiopia
| | - Chernet Getnet Asres
- Department of Midwifery, School of Health Sciences, Madda Walabu University, Bale Robe, Ethiopia
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Afulani PA, Oboke EN, Ogolla BA, Getahun M, Kinyua J, Oluoch I, Odour J, Ongeri L. Caring for providers to improve patient experience (CPIPE): intervention development process. Glob Health Action 2023; 16:2147289. [PMID: 36507905 PMCID: PMC9754039 DOI: 10.1080/16549716.2022.2147289] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/10/2022] [Indexed: 12/15/2022] Open
Abstract
A growing body of research has documented disrespectful, abusive, and neglectful treatment of women in facilities during childbirth, as well as the drivers of such mistreatment. Yet, little research exists on effective interventions to improve Person-Centred Maternal Care (PCMC)-care that is respectful and responsive to individual women's preferences, needs, and values. We sought to extend knowledge on interventions to improve PCMC, with a focus on two factors - provider stress and implicit bias - that are driving poor PCMC and contributing to disparities in PCMC. In this paper we describe the process towards the development of the intervention. The intervention design was an iterative process informed by existing literature, behaviour change theory, formative research, and continuous feedback in consultation with key stakeholders. The intervention strategies were informed by the Social Cognitive Theory, Trauma Informed System framework, and the Ecological Perspective. This process resulted in the 'Caring for Providers to Improve Patient Experience (CPIPE)' intervention, which has 5 components: provider training, peer support, mentorship, embedded champions, and leadership engagement. The training includes didactic and interactive content on PCMC, stress, burnout, dealing with difficult situations, and bias, with some content integrated into emergency obstetric and neonatal care (EmONC) simulations to enable providers apply concepts in the context of managing an emergency. The other components create an enabling environment for ongoing individual behavior and facility culture change. The pilot study is being implemented in Migori County, Kenya. The CPIPE intervention is an innovative theory and evidence-based intervention that addresses key drivers of poor PCMC and centers the unique needs of vulnerable women as well as that of providers. This intervention will advance the evidence base for interventions to improve PCMC and has great potential to improve equity in PCMC and maternal and neonatal health.
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Affiliation(s)
- Patience A. Afulani
- Epidemiology and Biostatistics Department, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco CA, USA
| | - Edwina N. Oboke
- Research Department, Global Programs for Research and Training, Nairobi, Kenya
| | - Beryl A. Ogolla
- Research Department, Global Programs for Research and Training, Nairobi, Kenya
| | - Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco CA, USA
| | - Joyceline Kinyua
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - James Odour
- Migori County Referral Hospital, Migori, Kenya
| | - Linnet Ongeri
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Burnett-Zieman B, Warren CE, Chiundira F, Mandala E, Kachale F, Mchoma CH, Mboma A, Kamanga M, Kazembe A. Modeling Pathways to Describe How Maternal Health Care Providers' Mental Health Influences the Provision of Respectful Maternity Care in Malawi. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2300008. [PMID: 38035724 PMCID: PMC10698235 DOI: 10.9745/ghsp-d-23-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/17/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Maternal health (MH) providers may experience traumatic events, such as maternal or fetal death, that can contribute to stress and burnout. Past trauma, poor working relationships, and under-resourced environments not only affect providers' own emotional well-being but also reduce their ability to provide respectful maternity care (RMC). METHODS Data were collected in mid-2021 as a cross-sectional survey with 302 MH providers working in 25 maternities in 3 districts in Malawi to measure burnout, depression, and post-traumatic stress disorder (PTSD). We present a pathway model describing how these factors interact and influence RMC. We used the provider-reported person-centered maternity care scale to measure RMC; the Maslach Burnout Inventory, which examines emotional exhaustion, depersonalization, and professional accomplishment; and standard validated screening tools to measure the prevalence of depression and PTSD. RESULTS Although levels of burnout varied, 30% of MH providers reported high levels of exhaustion, feelings of cynicism manifesting as depersonalization toward their clients (17%), and low levels of professional accomplishment (42%). Moderate to severe depression (9%) and suicidal ideation within the past 2 weeks (10%) were also recorded. Many (70%) reported experiencing an event that could trigger PTSD, and 12% reported at least 4 of 5 symptoms in the PTSD scale. Path analysis suggests that depression and emotional exhaustion negatively influence RMC, and depersonalization is mediated through depression. PTSD has no direct effect on RMC, but increased PTSD scores were associated with increased burnout and depression scores. Positive relationships with facility managers were significantly associated with increased RMC and decreased emotional exhaustion and depersonalization. CONCLUSION Burnout will continue to be a challenge among MH providers. However, pragmatic approaches for improving teamwork, psychosocial, and managerial support for MH providers working in challenging environments may help mitigate burnout, improve MH provider well-being, and, in turn, RMC for women seeking MH services.
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Affiliation(s)
| | | | | | - Edina Mandala
- Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Fannie Kachale
- Reproductive Health Directorate, Ministry of Health, Lilongwe, Malawi
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Zhong X, Hu R, Afulani PA, Li X, Guo X, He T, Li D, Li Z. Cross-cultural adaptation and psychometric properties of the Chinese version of the Person-Centered Maternity Care Scale. BMC Pregnancy Childbirth 2023; 23:652. [PMID: 37689683 PMCID: PMC10492356 DOI: 10.1186/s12884-023-05959-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/28/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Increasing evidence show that women across the world face unacceptable mistreatment during childbirth. Person-centered maternity care is fundamental and essential to quality of healthcare services. The aim of this study was to translate and determine the psychometric properties of the Person-Centered Maternity Care (PCMC) Scale among Chinese postpartum women. METHODS A cross-sectional study was conducted among 1235 post-partum women in China. The cross-cultural adaptation process followed the Beaton intercultural debugging guidelines. A total of 1235 women were included to establish the psychometric properties of the PCMC. A demographic characteristics form and the PCMC were used for data collection. The psychometric properties of the PCMC were evaluated by examining item analysis, exploratory factor analysis, known-groups discriminant validity, and internal consistency. RESULTS The number of extracted common factors was limited to three (dignity & respect, communication & autonomy, supportive care), explaining a total variance of 40.8%. Regarding internal consistency, the Cronbach's alpha coefficient and split-half reliability of the full PCMC score were 0.989 and 0.852, respectively. CONCLUSIONS The Chinese version of the PCMC is a reliable and valid tool to assess person-centered care during childbirth in China.
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Affiliation(s)
- Xiaoying Zhong
- Department of Nursing, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
| | - Rong Hu
- Department of Nursing, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China
| | - Patience A Afulani
- Department of Epidemiology and Biostatistics, University of California, San San Francisco, California, USA
| | - Xixi Li
- Department of Nursing, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, China Philippines Women's University, Manila, Philippines.
| | - Xiujing Guo
- Department of Nursing, West China Second University Hospital, Sichuan University / Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
| | - Tingting He
- Nephrology department, The Third Hospital of Mianyang, Sichuan Mental Health Center/ The Third Hospital of Mianyang (Sichuan Mental Health Center), Mianyang, China
| | - Dehua Li
- Department of Nursing, West China Second University Hospital, Sichuan University / Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Zuowei Li
- Department of Nursing, The Third Hospital of Mianyang, Sichuan Mental Health Center/ The Third Hospital of Mianyang (Sichuan Mental Health Center), Mianyang, China
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Watt MH, Minja LM, Barabara M, Mlay P, Stephens MJ, Olomi G, Mlay J, Marchand V, Mmbaga BT, Hanson OR, Cohen SR. A simulation and experiential learning intervention for labor and delivery providers to address HIV stigma during childbirth in Tanzania: study protocol for the evaluation of the MAMA intervention. BMC Pregnancy Childbirth 2023; 23:181. [PMID: 36927460 PMCID: PMC10018883 DOI: 10.1186/s12884-023-05482-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The experience of HIV stigma during intrapartum care can impact women's trust in the health care system and undermine their long-term commitment to HIV care engagement. Delivery of respectful maternity care (RMC) to women living with HIV (WLHIV) can improve quality of life and clinical outcomes. The goal of this study is to conduct an evaluation of MAMA (Mradi wa Afya ya Mama Mzazi, Project to Support the Health of Women Giving Birth), a simulation team-training curriculum for labor and delivery providers that addresses providers' instrumental and attitudinal stigma toward WLHIV and promotes the delivery of evidence-based RMC for WLHIV. METHODS The MAMA intervention will be evaluated among healthcare providers across six clinics in the Kilimanjaro Region of Tanzania. To evaluate the impact of MAMA, we will enroll WLHIV who give birth in the facilities before (n = 103 WLHIV) and after (n = 103 WLHIV) the intervention. We will examine differences in the primary outcome (perceptions of RMC) and secondary outcomes (postpartum HIV care engagement; perceptions of HIV stigma in the facility; internal HIV stigma; clinical outcomes and evidence-based practices) between women enrolled in the two time periods. Will also assess participating providers (n = 60) at baseline, immediate post, 1-month post training, and 2-month post training. We will examine longitudinal changes in the primary outcome (practices of RMC) and secondary outcomes (stigma toward WLHIV; self-efficacy in delivery intrapartum care). Quality assurance data will be collected to assess intervention feasibility and acceptability. DISCUSSION The implementation findings will be used to finalize the intervention for a train-the-trainer model that is scalable, and the outcomes data will be used to power a multi-site study to detect significant differences in HIV care engagement. TRIAL REGISTRATION The trial is registered at clinicaltrials.gov, NCT05271903.
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Affiliation(s)
- Melissa H. Watt
- grid.223827.e0000 0001 2193 0096Intermountain Healthcare, Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake, UT 84102 USA
| | - Linda M. Minja
- grid.412898.e0000 0004 0648 0439Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Mariam Barabara
- grid.412898.e0000 0004 0648 0439Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Pendo Mlay
- grid.415218.b0000 0004 0648 072XDepartment of Obstetrics and Gynecology, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Maya J. Stephens
- grid.223827.e0000 0001 2193 0096Intermountain Healthcare, Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake, UT 84102 USA
| | | | - Janeth Mlay
- grid.412898.e0000 0004 0648 0439Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Virginie Marchand
- grid.26009.3d0000 0004 1936 7961School of Medicine, Duke University, Durham NC, USA
| | - Blandina T. Mmbaga
- grid.412898.e0000 0004 0648 0439Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Olivia R. Hanson
- grid.223827.e0000 0001 2193 0096Intermountain Healthcare, Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake, UT 84102 USA
| | - Susanna R. Cohen
- grid.223827.e0000 0001 2193 0096Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT USA
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Afulani PA, Okiring J, Aborigo RA, Nutor JJ, Kuwolamo I, Dorzie JBK, Semko S, Okonofua JA, Mendes WB. Provider implicit and explicit bias in person-centered maternity care: a cross-sectional study with maternity providers in Northern Ghana. BMC Health Serv Res 2023; 23:254. [PMID: 36918860 PMCID: PMC10015736 DOI: 10.1186/s12913-023-09261-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Person-centered maternity care (PCMC) has become a priority in the global health discourse on quality of care due to the high prevalence of disrespectful and lack of responsive care during facility-based childbirth. Although PCMC is generally sub-optimal, there are significant disparities. On average, women of low socioeconomic status (SES) tend to receive poorer PCMC than women of higher SES. Yet few studies have explored factors underlying these inequities. In this study, we examined provider implicit and explicit biases that could lead to inequitable PCMC based on SES. METHODS Data are from a cross-sectional survey with 150 providers recruited from 19 health facilities in the Upper East region of Ghana from October 2020 to January 2021. Explicit SES bias was assessed using situationally-specific vignettes (low SES and high SES characteristics) on providers' perceptions of women's expectations, attitudes, and behaviors. Implicit SES bias was assessed using an Implicit Association Test (IAT) that measures associations between women's SES characteristics and providers' perceptions of women as 'difficult' or 'good'. Analysis included descriptive statistics, mixed-model ANOVA, and bivariate and multivariate linear regression. RESULTS The average explicit bias score was 18.1 out of 28 (SD = 3.60) for the low SES woman vignette and 16.9 out of 28 (SD = 3.15) for the high SES woman vignette (p < 0.001), suggesting stronger negative explicit bias towards the lower SES woman. These biases manifested in higher agreement to statements such as the low SES woman in the vignette is not likely to expect providers to introduce themselves and is not likely to understand explanations. The average IAT score was 0.71 (SD = 0.43), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education had significantly lower explicit bias scores on the low SES vignette than those with less education. Providers in private facilities had higher IAT scores than those in government hospitals. CONCLUSIONS The findings provide evidence of both implicit and explicit SES bias among maternity providers. These biases need to be addressed in interventions to achieve equity in PCMC and to improve PCMC for all women.
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Affiliation(s)
- Patience A Afulani
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th St, San Francisco, CA, 94158, USA.
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Jerry John Nutor
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, USA
| | | | | | - Sierra Semko
- Department of Psychology, University of California, Berkeley, Berkeley, USA
| | - Jason A Okonofua
- Department of Psychology, University of California, Berkeley, Berkeley, USA
| | - Wendy Berry Mendes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, USA
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Getahun M, Oboke EN, Ogolla BA, Kinyua J, Ongeri L, Sterling M, Oluoch I, Lyndon A, Afulani PA. Sources of stress and coping mechanisms: Experiences of maternal health care providers in Western Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001341. [PMID: 36962929 PMCID: PMC10022275 DOI: 10.1371/journal.pgph.0001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/11/2023] [Indexed: 02/12/2023]
Abstract
The dynamic and complex nature of care provision predisposes healthcare workers to stress, including physical, emotional, or psychological fatigue due to individual, interpersonal, or organizational factors. We conducted a convergent mixed-methods study with maternity providers to understand their sources of stress and coping mechanisms they adopt. Data were collected in Migori County in western Kenya utilizing quantitative surveys with n = 101 maternity providers and in-depth interviews with a subset of n = 31 providers. We conducted descriptive analyses for the quantitative data. For qualitative data, we conducted thematic analysis, where codes were deductively developed from interview guides, iteratively refined based on emergent data, and applied by a team of five researchers using Dedoose software. Code queries were then analysed to identify themes and organized using the socioecological (SE) framework to present findings at the individual, interpersonal, and organizational levels. Providers reported stress due to high workloads (61%); lack of supplies (37%), poor salary (32%), attitudes of colleagues and superiors (25%), attitudes of patients (21%), and adverse outcomes (16%). Themes from the qualitative analysis mirrored the quantitative analysis with more detailed information on the factors contributing to each and how these sources of stress affect providers and patient outcomes. Coping mechanisms adopted by providers are captured under three themes: addressing stress by oneself, reaching out to others, and seeking help from a higher power. Findings underscore the need to address organizational, interpersonal, and individual level stressors. Strategies are needed to support staff retention, provide adequate resources and incentives for providers, and ultimately improve patient outcomes. Interventions should support and leverage the positive coping mechanisms identified.
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Affiliation(s)
- Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | | | | | | | | | - Mona Sterling
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Audrey Lyndon
- NYU Rory Meyers College of Nursing, New York, NY, United States of America
| | - Patience A. Afulani
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
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Watt MH, Cohen SR, Minja LM, Barabara M, Mlay P, Stephens MJ, Olomi G, Mlay J, Marchand V, Mmbaga BT. A simulation and experiential learning intervention for labor and delivery providers to address HIV stigma during childbirth in Tanzania: Study protocol for the evaluation of the MAMA intervention. RESEARCH SQUARE 2023:rs.3.rs-2285235. [PMID: 36778232 PMCID: PMC9915785 DOI: 10.21203/rs.3.rs-2285235/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background : The experience of HIV stigma during intrapartum care can impact women's trust in the health care system and undermine their long-term commitment to HIV care engagement. Delivery of respectful maternity care (RMC) to WLHIV can improve quality of life and clinical outcomes. The goal of this study is to conduct an evaluation of MAMA (Mradi wa Afya ya Mama Mzazi, Project to Support the Health of Women Giving Birth), a simulation team-training curriculum for labor and delivery providers that addresses providers' instrumental and attitudinal stigma toward WLHIV and promotes the delivery of evidence-based RMC for WLHIV. Methods : The MAMA intervention will be evaluated among healthcare providers across six clinics in the Kilimanjaro Region of Tanzania. To evaluate the impact of MAMA, we will enroll WLHIV who give birth in the facilities before (n=103 WLHIV) and after (n=103 WLHIV) the intervention. We will examine differences in the primary outcome (perceptions of RMC) and secondary outcomes (postpartum HIV care engagement; perceptions of HIV stigma in the facility; internal HIV stigma; clinical outcomes and evidence-based practices) between women enrolled in the two time periods. Will also assess participating providers (n=60) at baseline, immediate post, 1-month post training, and 2-month post training. We will examine longitudinal changes in the primary outcome (practices of RMC) and secondary outcomes (stigma toward WLHIV; self-efficacy in delivery intrapartum care). Quality assurance data will be collected to assess intervention feasibility and acceptability. Discussion : The implementation findings will be used to finalize the intervention for a train-the-trainer model that is scalable, and the outcomes data will be used to power a multi-site study to detect significant differences in HIV care engagement. Trial Registration : The trial is registered at clinicaltrials.gov, NCT05271903.
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Nutor JJ, Aborigo RA, Okiring J, Kuwolamo I, Dorzie JBK, Getahun M, Mendes WB, Afulani PA. Individual and situational predictors of psychological and physiological stress and burnout among maternity providers in Northern Ghana. PLoS One 2022; 17:e0278457. [PMID: 36520845 PMCID: PMC9754239 DOI: 10.1371/journal.pone.0278457] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Maternity providers, including nurses, midwives, physicians, are at significant risk for stress and burnout due to the nature of care provision in maternal and child health settings. Yet, the empirical evidence on stress and burnout among maternity providers in sub-Saharan Africa is scarce. Therefore, the purpose of our study was to (1) assess levels of stress and burnout among maternity providers and support staff in Ghana, and (2) identify individual and situational factors associated with maternity provider stress, burnout, and physiology. METHOD Using a purposive sampling technique, we recruited 150 maternity providers from 19 high delivery health facilities within the 15 districts of the Upper East region (UER) of Ghana into a cross-sectional study. Participants completed Cohen's Perceived Stress Scale, the Shirom-Melamed Burnout scale, and sociodemographic, health-, and work-related items. Participants' heart rate variability (HRV) and hair cortisol levels were assessed for stress-related physiologic responses. We computed bivariate and multivariate linear regression models to examine factors associated with stress and burnout. RESULT Most participants were experiencing moderate to high stress (58.0%) and burnout (65.8%). Each unit increase in overcommitment to work was associated with 0.62 higher perceived stress scores (β = 0.62, 95% CI: 0.22, 1.02) and 0.15 higher burnout scores. On average, those who had experienced disrespect from colleagues in the last year had higher perceived stress scores compared to those who had not experienced disrespect (β = 1.77, 95% CI: 0.50, 3.04); and those who had experienced disrespect from patients in the last year had higher cortisol levels than those who had not (β = 0.52, 95% CI: 0.11, 0.93). Those who work for more than 5 days also had higher cortisol levels, on average, compared to those who worked fewer days a week. CONCLUSION We found high levels of stress and burnout among maternity providers in Northern Ghana, underscoring the need for interventions to manage the effects of stress and burnout on maternity providers' wellbeing, quality of care, and patient outcomes. Healthcare management teams should assist providers in reducing their overcommitment by hiring more staff, given its strong link to stress and burnout. Additionally, facilitating a respectful workplace culture could also help reduce stress and burnout among maternity providers.
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Affiliation(s)
- Jerry John Nutor
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | | | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Wendy Berry Mendes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Patience A. Afulani
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
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