In total, 27 mothers and 25 nurses participated in the pre-intervention focus groups, and 42 mothers, 31 nurses, and 19 CHWs joined the post-intervention focus groups (Table 1). FGDs were held at healthcare facilities in the communities of Nyang’oma, Katito, Sondu, Masogo, Muhoroni, and Nyakach. Each focus group was well attended despite the late arrival of some participants.
Table 1. Timing, participant category, number of participants, and location of focus group discussions in Western Kenya (2013-2014)
|
Number of FGDs
|
Number of Participants
Mean (Range)
|
Facility Locations
|
Pre-intervention (2013)
|
|
|
|
|
Mothers
|
4
|
6.75 (6-8)
|
Nyang'oma, Katito, Sondu, and Masogo
|
|
|
|
|
|
|
Nurses
|
4
|
8.75 (7-10)
|
Katito, Muhoroni, Masogo, and Sondu
|
|
|
|
|
|
Post-intervention (2014)
|
|
|
|
|
Mothers
|
5
|
8.4 (8-10)
|
Muhoroni, Masogo, Nyang'oma, Katito, and Nyakach
|
|
|
|
|
|
|
Nurses
|
4
|
7.75 (7-9)
|
Muhoroni, Masogo, Katito, and Sondu
|
|
|
|
|
|
|
CHW
|
2
|
9.5 (9-10)
|
Awasi*, Katito
|
Note*: One post-intervention FGD was held at SWAP office in Awasi. All other FGDs were held at health facilities.
Table 2 summarizes a list of themes, sub-themes, and categories identified in pre- and post-intervention FGDs for mothers, nurses, and CHWs. Figure 1 illustrates a conceptual model to explain ANC visits and facility-based delivery based on FGDs.
Table 2. Identified themes and sub-themes from focus group discussions (FGDs) with mothers, nurses, and community health workers.
Participant
|
Timing
|
Theme 1
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Theme 2
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Theme 3
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Theme 4
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Theme 5
|
Theme 6
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Mother
|
Pre
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Perceived quality of care at health facilities -Positive -Negative -Mixed
|
Perceptions on home delivery -Positive -Negative
|
Perceived barriers to ANC visits and facility-based delivery -Money -Work -Transport -Safety and Security -Fear of mistreatment -Time -Supply shortage at healthcare facilities
|
Proposed topics for text messages -ANC appointment reminder -family planning -malaria -water treatment -nutrition -immunization -HIV/AIDS
|
|
|
Post
|
Perceived quality of care at healthcare facilities -Rude attitude and conduct of nurses -Sympathy for nurses
|
Perceptions on home delivery -Positive -Negative
|
Perceived barriers to ANC visits and facility-based delivery -fear -lack of supplies and electricity -cultural beliefs
|
Overall experience with SWAP and OBA -Positive -OBA more valued
|
Experience with group education -Limited exposure -Beneficial to break cultural myths
|
Experience with SMS text messages -Literacy issue -Message reaching husband's phone
|
Nurse
|
Pre
|
Challenges with providing quality care -Inadequate training -limited equipment and supplies -workforce shortage
|
Barriers to ANC visits and facility-based delivery -poor roads -stigma -distance to healthcare facilities -geographic terrains -adverse weather
|
|
|
|
|
Post
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Factors that make nurses better -Training -Specialization -Good supervision -Adequate staff and supplies -Rewards
|
Challenges with providing quality care -Lack of equipment and supplies -Inadequate recognition -Limited teamwork -Inadequate compensation -Workforce shortage
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Perspectives on mothers and community health workers -Nurses' attitude as a hindrance to ANC visits -Need for financial incentives for community health workers
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Experience with SWAP and OBA -Positive -Unintended consequences -Remaining challenges
|
Sustainability of existing programs -Concerns for the termination of programs
|
|
Community Health Worker
|
Post
|
Perceptions of training -Satisfied -Not enough
|
Experience with SWAP program -Increased patients, ANC visits and hospital delivery -Challenges with product distribution availability -Benefits of health talks -Challenges with text messages
|
|
|
|
|
Quality of care
Quality of care at healthcare facilities. From pre- and post-FGDs, quality of care emerged as a major theme among mothers. It includes the following sub-themes: perceptions on quality of care at healthcare facilities, challenges with providing quality care at healthcare facilities, factors that make nurses better to provide care, and perceptions on quality of care at home. Mothers shared positive, negative and mixed perceptions on the quality of care provided at ANC and delivery at healthcare facilities:
I was also welcomed so well, and they asked me questions which I answered. Then, there were some drugs that I was given to swallow. Then, I was told to lie on the bed, and they palpated my tummy, and they wrote for me the date in which I was supposed to come back. I can say that I was happy with the way I was handled (positive).
– Nyang’oma Pre-Intervention FGD, Mother #5 –
I just delivered on my own. They did not help me. I asked them why they are not helping me, and they said that they don’t know about mine (negative).
– Katito Post-Intervention FGD, Mother #5 –
Hospital delivery is good but only if you get a good nurse. Some of them really mistreat mothers, they insult you, and so it only depends on the nurse that you get (mixed).
– Katito Pre-Intervention FGD, Mother #3 –
While some participants mentioned nurses’ rude attitude, arrogance, and violent behaviors, one mother in a post-intervention FGD shared her sympathy for nurses and described how a nurse strives to complete multiple tasks at once.
There is only one nurse who is doing rounds in the wards, and she also wants to attend to you. If there could be at least more than one nurse, then things could be very easy.
– Nyakach Post-Intervention FGD, Mother #5 –
Another recurrent topic was that complications from pregnancy and delivery can be managed well at healthcare facilities. Other participants also explained that HIV transmission during delivery can be better prevented at healthcare facilities than at home and that injections are available for bleeding and post-pregnancy pain. Based on these positive perceptions of healthcare facilities, most of the mothers expressed that they want to deliver the next child at healthcare facilities despite the concern of mistreatment.
Challenges with providing quality care at healthcare facilities. Another sub-theme regarding quality of care was addressed by nurses, who described challenges with providing quality care at healthcare facilities. Some of the challenges include inadequate training, limited equipment and supplies, and workforce shortage. Nurses expressed the need and importance of training and updates to provide the most effective care and avoid outdated approaches to care. On resource limitations, nurses also stated:
“Maybe you are in the labor ward, you have no delivery packs, and there is no water. Maybe there is somebody to be referred, and there is no vehicle. Maybe you are in the maternity, and you have no gloves. Those are some of the things that make my work difficult sometimes.”
– Murohoni Pre-Intervention FGD, Nurse #8 –
“I feel understaffing is the most challenging because if you are alone and you are pressed with a lot of work to do, you cannot really provide your services effectively. You are one person. You want to attend to the mothers. You are attending to the children. There you are giving injections. You are giving the drugs, and you are competing with time.”
– Katito Pre-Intervention FGD, Nurse #1 –
Post-intervention FGDs for nurses also mentioned resource constraints and additionally highlighted inadequate recognition, teamwork, and compensation as the factors that discourage nurses and lead to suboptimal care. Furthermore, the discussion emphasized understaffing as the major challenge faced by nurses.
It gives us a burnout, and even anger can flare out because expectation from outside is too much.
– Katito Post-Intervention FGD, Nurse #9 –
Factors that make nurses better to provide care. FGDs also identified a number of factors that can enhance nurses’ productivity at work, such as training, specialization, good supervision, adequate staff and supplies, and rewards (e.g., financial rewards, acknowledgment of efforts). In regards to better work environment, a nurse stated that:
The most important thing is that they should avail the equipment and better conditions for nurses to work. You know there are places where nurses even work without gloves, without instruments, and even without the necessary essential drugs….I think so many nurses are demotivated.
– Sondu Post-Intervention FGD, Nurse #1 –
Perceptions on home delivery. The majority of mothers shared their recognition of home delivery with traditional birth attendants as unsafe practice or at least suboptimal practice. Yet, a few participants expressed her perspective on the value of using traditional herbs to facilitate delivery at home.
What I saw in a friend is that if the placenta refuses to come out they [traditional birth attendants] can give you traditional herbs of which if you are given, it can easily remove it faster, but in hospital at times they can still want to insert their hands or even want to do you an operation.
– Masogo Pre-Intervention FGD, Mother #1 –
“At times you have Rariu, and sometimes your delivery becomes complicated, and it’s only the TBA [traditional birth attendant] that can help you until the Rariu (i.e., a folk diagnosis where pain is felt by pregnant women in the lower abdomen) goes away since they are the people who know how to manage it.”
– Katito Post-Intervention FGD, Mother #7 –
In response to participants’ concern and experience of mistreatment by nurses, home delivery was also viewed as a favorable option by a few participants. One mother shared,
“It is not safe but at least they don’t harass you the way the sisters [nurses] do.”
– Nyang’oma Pre-Intervention FGD, Mother #4 –
Expressing a similar perspective regarding the kind of care given at home, another mother offered,
“Some women can help you if you give birth at home, the women who are serious. They can help you in that they pamper and tend to be faster, while in the hospital you may get some nurses who don’t mind about you. They take long to even attend to you.”
– Katito Pre-Intervention FGD, Mother #2 –
Some participants shared negative views on home delivery as it cannot respond to complications quickly and safely. After the concurrent implementation of SWAP interventions and OBA program, participants reported that home delivery is rather costly. A mother stated that:
“What I can say about delivering at home is that it is not good because in the hospital, delivery is free unlike home. TBA wants to be paid. There is also some ashes that they give you when you feel labor to make the baby come out even when the time is not yet. This may make the baby die, and they end up taking your money as well.”
– Nyang’oma Post-Intervention FGD, Mother #5 –
Barriers to antenatal care and facility-based delivery
Patient perceptions on barriers to antenatal care and facility-based delivery. The second major theme that emerged from FGDs was barriers to antenatal care and facility-based delivery, which addresses the perceptions of mothers and nurses. Mothers in pre-intervention FGDs listed a number of factors that prevent people from visiting healthcare facilities for ANC visits and delivery, including money, work, transportation, security and safety, fear of mistreatment by nurses, time, and supply shortage at healthcare facilities. Participants shared that people may not have money to pay for their first-time hospital fee of 100-150 Kenyan Shillings, and work (e.g., drying maize outside of the home) could prevent them from leaving for ANC. Describing the concerns about traveling to the health facility at night, a mother stated,
“When labor starts in the morning, then I will come and deliver here at Nyang’oma. If it starts at night, it can be very risky. We live next to the road and when it reaches at night, there is a lot of chaos…I would not like to risk. So, if it is during the day, I will just come to the hospital, but if it is at night, then I will have to deliver at home.”
– Nyang’oma Pre-Intervention FGD, Mother #5 –
Multiple mothers also expressed their fear of mistreatment by healthcare providers. One of the mothers stated that, “I feel I have some fear because I hear rumors that nurses at [a specific facility] sometimes mistreat you when they know that your delivery time is not ready. Sometimes you know labor can start early and then you take time before delivering.”
– Nyang’oma Pre-Intervention FGD, Mother #7 –
FGDs also discussed fear, lack of supplies and electricity, and cultural beliefs serve as major barriers to ANC visits and facility-based delivery. Mothers explained that some mothers do not like ANC because many questions will be asked at the first ANC visit. The types of fear include fear of HIV test, injection, language, and walking while being pregnant. A mother spoke about the fear of knowing her HIV status and explained that it delayed her timing of seeking care.
Nurse perceptions on barriers to antenatal care and facility-based delivery. Nurses also identified a list of barriers to ANC visits and facility-based delivery, including poor roads, stigma, distance to healthcare facilities, geographic terrains (e.g., steep hill), and adverse weather. Speaking to how stigma may influence ANC visits, one nurse stated that stigma associated with HIV/AIDS prevents people from returning to ANC visits or delivering at healthcare facilities once they find out their positive status.
SWAP and OBA Interventions
Proposed topics for text messages. The last major theme from FGDs was SWAP and OBA interventions. When pre-intervention FGD moderators asked mothers to suggest topics for text messages, participants expressed their interest in the following topics: reminder of ANC appointments, family planning, malaria, water treatment, nutrition, immunization, and HIV/AIDS. These responses informed SWAP’s intervention to develop health education and reminder messages by text.
Perceptions on intervention effects. Mothers shared their appreciation to and contribution of SWAP interventions and the OBA program. Some participants valued the OBA program more than SWAP interventions because it substantially reduced healthcare costs and provided a sense of ease.
“They [SWAP interventions and OBA] are both important. One helped me because I gave birth free of charge, and the other one, every time I came from the clinic, I could fill my bag with the item that I was given at the shop there.”
– Masogo Post-Intervention FGD, Mother #9 –
They are both good, but I can say that OBA card was the best because it was catering for a lot of things that if we were to pay cash then maybe we wouldn’t.
– Nyakach Post-Intervention FGD, Mother #3 –
Nurses identified positive effects and remaining challenges of SWAP interventions and spoke to how SWAP interventions enhanced their work and service utilization:
SWAP was able to see that the last time we didn’t have electricity, so they installed for us a solar [system]. So in the night when we have a blackout, we simply use the solar system. So, this has improved our uptake and the clients are able to deliver at night even when we have a blackout.
– Katito Post-Intervention FGD, Nurse #8 –
At the same time, the discussion uncovered some unintended consequences of SWAP interventions. A nurse shared that mothers come to deliver at healthcare facilities with an expectation that they receive incentives, so they did not come with any baby care package. Another nurse also stated:
The negative part of it [increased clients] is that we have a high workload that sometimes cannot allow us to give quality service because we are struggling to finish the queue, and we miss giving some education to our clients. You find that when it comes to health talks like the danger signs, breast feeding education and other things, you find that time doesn’t allow us.
– Katito Post-Intervention FGD, Nurse #5 –
As an untended consequence, nurses also shared how they could develop a negative attitude toward mothers at their facilities.
At times, we also have attitude which sometimes really make these mothers not to come and deliver in the hospital. Many times you find that these mothers are saying that they will be slapped…. Sometimes the nurse will ask so many questions that they don’t like, and they are going to be intimidated. So, we should be well-staffed, and then as nurses, we should work on our attitude. Like how you talk to them in that situation will also attract the others to the hospital, and we provide the care.
– Sondu Post-Intervention FGD, Nurse #6 –
Nurses also discussed how the OBA program contributed to reducing their stress level during the night when they have difficult delivery. A participant explained that she can call an ambulance, and it takes care of the challenge. The OBA program also provided additional financial source for the healthcare facilities to conduct outreach activities and benefit people in remote villages. The remaining challenge identified in the discussion was transportation for referral. “For now, OBA is giving us support. They have paid for transport, but still the ambulance is the same one. You call. It’s not there.”
– Masogo Post-Intervention FGD, Nurse #6 –
CHWs discussed how SWAP and OBA interventions contributed to increasing patients, ANC visits, and hospital deliveries and revealed that SWAP products were not necessarily available all the time or for nurses, which created some frustrations for mothers and nurses.
Even if it was getting late, they could still persevere and wait because of the good thing that they were going to get.
– Awasi Post-Intervention FGD, CHWt #3 –
The ANC turn up was very low but when we started giving mothers vouchers, the deliveries went up, and the number we were seeing in the ANC also went higher. They could come in large numbers, something that was not happening before.
– Awasi Post-Intervention FGD, CHW #7 –
You find that the products are brought around the fifteenth there. So when it is brought, it takes like only two weeks, and it is finished. When it gets finished on that thirtieth, there are some women who come to the clinic on the first day of every month or second or even third depending on whether those dates fall on a weekday. So ever since this woman came for the products, she has never got or seen any product.
– Awasi Post-Intervention FGD, CHW #10 –
Perceptions of group education. FGD participants attended health talks only once or never attended them. While the level of exposure could be low, some participants shared the benefits of health talks to break cultural myths and make new friends.
“Before I gave birth to my first-born, I used to hear people telling me that you are not supposed to buy clothes for the unborn baby. If you do that then, it is a taboo, and your child can die before it is born. So, I used not to buy clothes for the baby. When I came for those meetings, I was told that ‘those people are misleading you. Can you try and buy and then let us see if something will happen to the child?’ I bought the clothes, and there is nothing that happened to my baby. I also learnt how to take care of myself and the baby hygienically.”
– Murohoni Post-Intervention FGD, Mother #4 –
“I also knew one woman the first day that I attended the meeting. So, we left together, and as we were chatting on the way, we exchanged numbers, and we always communicate. Of late she called and asked me whether I still go back to the clinic, and I said yes.”
– Murohoni Post-Intervention FGD, Mother #1 –
Nurses also shared how group education was useful for organizing mothers. One nurse stated,
“When I came to understand that we were going to book them as per the expected date of delivery, it really made our clinic to be organized. We are handling clients as individuals as per that cohort.”
– Katito Post-Intervention FGD, Nurse #1 –
CHWs reported that their group education sessions addressed nutrition, birth plans, malaria, and safe water practice (e.g., not carrying large amount of water). While a few challenges including late arrival of mothers and space limitation were noted, the discussions uncovered how health talks benefited women and CHWs.
That health talk really helped the women. You find that when we grouped them, you find that even the school girls who are pregnant are free to share since we make the environment conducive for them. I do make them to have partners and discuss among themselves so they would share freely.
– Katito Post-Intervention FGD, CHW #2 –
We get to even ask the nurses about certain things that make us as well gain knowledge as they also get knowledge. This is then happiness to both of us.
– Katito Post-Intervention FGD, CHW #9 –
Perceptions of text messages. Mothers reported that they did not receive text messages for ANC appointment reminders but shared their experience with health education messages. A participant shared that reading in Luo was difficult for her while she could speak the language well. The discussion also revealed that health education messages reached the phone of husbands instead of mothers, and the sender of health education messages was not clear.
I got my phone through my husband’s phone. I was at home when the message arrived, and he was away from home. He told me that there was a message that he received from SWAP, but he accidentally deleted the message, so I did not get to read the message.
– Masogo Post-Intervention FGD, Mother #1 –
When the first time the messages came, I read them, and I thought it came to my phone by mistake. What made me know that it came from SWAP was when I scrolled down, I saw SWAP name down at the end of the message.
– Masogo Post-Intervention FGD, Mother #4 –
CHWs also shared their experience with text messages. A challenge shared in FGDs accords with mothers’ experiences.
The major challenge that I have encountered is that some young women come here. They give us their telephone numbers, and when we give you these numbers, and when they are called, you find that the husband quarrels claiming that who gave you my number, and so it is not easy to schedule a health talk since they say that the husbands will not agree.
– Katito Post-Intervention FGD, CHW #2 –
Perceptions of Training. CHWs discussed the training that they received prior to the SWAP intervention, and they mentioned a list of topics including record keeping, importance of hospital delivery, immunization, safe water, danger signs among pregnant women, nutrition, and basic business skills (e.g., reconciliation of voucher). A few participants shared that two days were not enough to understand record keeping practice and reconciliation, but many participants expressed their satisfaction with the training that they received. Nurses expressed their appreciation toward training provided on resuscitation, obstetric emergency response, water and hygiene, and education through listening.
Perceptions on program sustainability. Most of the participants expressed their hope to continue the intervention activities and shared some potential consequences of ending them. A nurse shared that:
“when partners are rolling out activities, they come with support and staff, upon exit, they integrate those services to the system and then the issue of shortage continues…I come to wonder why all services are being integrated, [and] they leave it to nurses.”
– Murohoni Post-Intervention FGD, Nurse #1 –
Nurses also discussed how CHWs may need financial incentives to continue performing their responsibilities. One of the participants stated:
In other places, you get some donors…paying the community workers, and other places, they are not being paid. Now that is where the challenge comes. You get maybe there is money in other parts, and in other parts there is no money. You know even those people in the community they also have their priorities, the community workers. They have to provide for their families, and some other added duties.
– Sondu FGD, Participant #4 –