Network survey
The eight PHCUs each consisted of one health centre and an average of 4.38 Health posts (SD 1.51) (see Table 1).
Approximately two thirds of the 160 participants were female, with health officers disproportionately male (88%), and midwives disproportionately female (81%) (Table 2). The average number of years of experience was 3.6, with 2.5 years at their current post. HEWs on average had the longest total experience and most years at their current post. Overall, 46% were trained or orientated in CBNC programme. All HEWs should be trained in CBNC and from this sample of 160, 78% reported being trained.
Network metrics
Across all networks and all PHCUs the following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65) Table 3 presents the network level statistics by network metric, allowing easy comparison of each network metric across networks and PHCUs. Additional File 3 presents the same data, grouped by PHCU providing an overview of each PHCU by network type. Patterns emerge with typically ANC and maternity advice networks being denser and having more ties than PNC and Newborn care advice networks. Half of the PHCUs had this same pattern across the networks with degree centrality. There were some exceptions: for PHCU E and F, ANC advice exchange was noticeably denser, however maternity, PNC and newborn care advice exchange networks had similar density. The other clear pattern was that certain PHCUs had more advice exchanging than others (PHCUs E and F had many more ties versus PHCUs A and B).
Actor-level network metrics
In addition to calculating network level properties, actor-level metrics were calculated and the cadre of the actor with the highest value is reported in Additional Table 4 for each of the networks. Midwives were far more likely to be the actor with the highest in-degree centrality, meaning the most people within the PHCU came to them for advice. This is highlighted in Additional File 5 and is true for all subject areas, although they were as equally sought as nurses for advice related to providing newborn care.
Visualisations
Each PHCU had their networks visualised both with dichotomised data, which facilitated aggregating the ties across networks, and valued data, which added a layer of understanding related to the frequency of interactions. To illustrate the variability within a PHCU across these networks, PHCU H was selected. Figure 1 visualises four dichotomised networks with advice seeking and giving for each care area aggregated into one. These sociograms show more ties and fewer isolates for ANC and maternity advice networks relative to PNC and newborn care advice networks.
Valued data were visualised in the same way (with respect to the node attribute data) as for the other sociograms with the exception that the line widths reflect the frequency of interaction (thicker lines reflecting greater frequency ranging from daily to yearly). PHCU A’s PNC advice seeking and advice giving sociograms were selected to illustrate in Figure 2 how there seems to be more individuals seeking advice than giving advice.
To show the variability across the PHCUs for a given type of network, maternity advice seeking was selected to show across all 8 PHCUs in Figure 3-4. For all of these graphs midwives play a central role, as expected, despite some variability. In Figure 3, PHCU D has only advice exchange happening at the HC with the exception of one HEW engaged, whereas in Figure 4, PHCU F has many HEWs engaged frequently with HC staff and even some HEWs seeking advice from each other. The intra and intercadre advice exchange depicted by PHCU F was more typical of the findings across PHCUs and topics for advice exchange. The data on formal supervisory structures were available only from a subset of those PHCUs that were selected for the qualitative inquiry. Due to staff turnover, only one could be analysed along with the quantitative network data. This example confirmed what was observed across other PHCUs, a willingness to engage in informal advice exchange outside of formal supervisory structures.
Off roster advice seeking
Of the four cadres of healthcare workers, health officers reported the fewest number of individuals they either sought or gave advice to who were not working within their PHCU. However, after adjusting for the different number of HCWs per cadre those distinctions largely disappear. For these HCWs more advice is sought off roster than they are giving to those outside of the PHCU. This is particularly the case for Health officers and HEWs. By far the most off roster advice exchange occurred for nurses and HEWs seeking advice regarding providing ANC.
Qualitative findings
Who is sought for advice and why?
Reasons for going to a specific person for advice were typically because of that specific person’s training and knowledge, less so because of their years of experience. One healthcare worker noted that because of their training in integrated community case management, PHCU colleagues seek their guidance. Some respondents said that they relied on formal supervisory structures, however they appeared relatively infrequent with most people describing qualities of the individuals’ knowledge and skills dictating their advice seeking behaviour rather than just formal structures. The examples of consulting supervisors related to situations where they “had some fear or discomfort with the situation and didn’t want to take accountability for something going wrong.” [Health officer, Tigray] Personality or level of comfort with the person was mentioned as a secondary factor that contributed to who was approached for advice.
In general, current PHCU colleagues were sought for advice, however if they were not available, former classmates and colleagues were the most common individuals sought for advice. For example, one respondent said he’d first go to experienced people in his PHCU, but if they are unable to give advice he would:
“call some peers, people who [I] went to school with and grew up with, working in other HCs or hospitals who have several years of experience, or even professors to ask for advice in complicated cases.” [Health Officer, Amhara]
This was consistent across cadres: health officers, nurses and HEWs for both routine and urgent questions. A nurse in Tigray described a case of postpartum haemorrhage when his supervisor was away at a training, so he had called a midwife he had previously worked with who was now at a different health centre. Several people within this PHCU mentioned seeking advice from this same midwife who had been transferred.
The furthest afield anyone mentioned seeking advice from was from a friend in Addis Ababa because colleagues within the PHCU did not know how to handle the situation. Only one person mentioned seeking advice from someone outside of the PHCU because of not being comfortable asking for a colleague’s advice. This does not appear to be a widespread concern for most healthcare workers.
Reasons for advice exchange
According to our respondents, the range of advice given on providing ANC care included many topics already covered in their training. One nurse explained that they need repetition because learning the content theoretically is so different from doing it practically. This was also the case for advice exchange around other service delivery areas.
“While the integrated community case management manual is very clear it seems that [the HEW I was advising] lacked confidence and contacted me at the health centre for reassurance.” [Nurse, Tigray]
While there are examples of advice being sought for providing antenatal care, it is noteworthy that many respondents said they felt comfortable providing ANC and believed they did not need advice. Several healthcare workers mentioned fearing deliveries and that those with less experience sought those with more for reassurance and guidance. A HEW described seeking advice from another HEW because she had referred more women to the health centre for delivery and she wondered what methods she was using that might be helpful in her own work.
Are advice needs being met?
All interviewees indicated that they had always been able to have their specific questions answered when seeking advice. Interviewers probed further, asking if there were ever situations in which they were unable to have their questions answered, and heard adamant statements from several respondents: “how would I treat them if I [still] needed advice?” [HEW, Amhara] and “[I] will not let uncertainties rest until [I] get [my] questions answered.” [HEW, Tigray]
No interviewees said they were unable to get the advice they needed, although some described asking more than one person or consulting other resources. This could reflect a response bias, an unwillingness to admit to providing care while having questions about providing that care. Or it could be that when they had a clear question they could generally find an answer. However, they only asked when they were aware that they did not know something. While their specific questions were addressed, many described a desire for additional training, because as one respondent said, “I will benefit from additional information I am not aware of” [Midwife, Oromia]
Barriers to advice exchange
Many of the HEWs said that they do not deliver babies, although as the closest HCWs to the community they are often involved in referral to the health centre. Some HEWs said they are not involved in postnatal care, although others said they are involved just for identifying dangers signs and referral.[1] When asked why people do not seek advice from her, a HEW said “the HC staff don’t ask because they are at a higher level of knowledge, education and training than me and that they would ask each other. They wouldn’t think to ask a HEW.” [HEW, Amhara]
Respondents commented on the logistical constraints in seeking advice. The poor mobile phone network in some rural areas was mentioned as a barrier, particularly in one PHCU’s catchment area, which had only gained network access within the last 8 months. “it [the mobile network] had affected it [advice seeking] before and I remedied this by handling the case to the best of [my] knowledge and asking later to clarify what [I] had done.”[Health Officer, Amhara]
Respondents commented that workload sometimes interfered with seeking advice for non-urgent cases. Advice exchange for these non-urgent situations typically happened in person in either at ad-hoc or routine meetings. If urgent, [from respondent’s perspective] mobile phones were used, particularly for HCWs seeking advice from more skilled providers at the health centre or woreda.
“[I] usually ask for advice by phone, especially in the case of emergencies and this advice seeking comes whenever a difficult case arises, once or twice a month. There is nothing stopping [me] from asking for advice as long as the phone networks are working. The network rarely fails around the HC so this is not a big hurdle“ [Health Officer, Tigray].
One HEW described her fellow HEW as being “intimidated easily to ask questions, so [I] served as a conduit.” [HEW, Amhara] Another said that “If I do not know the answer, I would call someone who is not here, does not work in this place.” [Midwife, Oromia] These were the only examples given even with probing with hypothetical reasons for why someone might not feel comfortable seeking advice from their colleagues within the PHCU. Another mentioned language as a possible barrier and that they “could access advice more easily” if rather than speaking in Amharic, they spoke in a local language as “this would avoid missing out on any information.”
[1] This is unusual. Postnatal care is explicitly part of the HEW package of services. However, they may have interpreted “care” to mean providing clinical care, in which case they refer women to health centres.