Factors Impacting The Effectiveness Of Health Care Worker


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FACTORS IMPACTING THE EFFECTIVENESS OF HEALTH CARE WORKER BEHAVIOR CHANGE
A LITERATURE REVIEW
May 20, 2016

ACKNOWLEDGEMENTS
The USAID-funded Health Communication Capacity Collaborative (HC3) – based at the Johns Hopkins Center for Communication Programs – would like to acknowledge Erin Kurtz for authoring this report with input from Heather Hancock and Katherine Holmsen. HC3 would like to thank Anna Ellis for her editing and layout support. HC3 would also like to thank Hope Hempstone at USAID for her invaluable feedback, guidance and support.
Suggested citation: The Health Communication Capacity Collaborative (HC3). (2016) Factors Impacting the Effectiveness of Health Care Worker Behavior Change: A Literature Review. Baltimore: Johns Hopkins Center for Communication Programs.
This report was made possible by the support of the American People through the United States Agency for International Development (USAID). The Health Communication Capacity Collaborative (HC3) is supported by USAID’s Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreement #AID-OAA-A-12-00058. ©2016, Johns Hopkins University. All rights reserved.

TABLE OF CONTENTS
ACRONYMS.................................................................................................................................................................................4 EXECUTIVE SUMMARY.............................................................................................................................................................5 INTRODUCTION.........................................................................................................................................................................6 METHODOLOGY........................................................................................................................................................................8 KEY FINDINGS............................................................................................................................................................................9   Knowledge and Competency Barriers........................................................................................................................9   Structural and Contextual Barriers...............................................................................................................................13   Attitudinal Barriers.............................................................................................................................................................20 CONCLUSION.............................................................................................................................................................................25 REFERENCES...............................................................................................................................................................................26 APPENDIX...................................................................................................................................................................................30

ACRONYMS

ART CCP FSW HC3 HCW HIV/AIDS PLWHA PMTCT SBCC TB USAID

Antiretroviral Therapy Johns Hopkins Center for Communications Programs Female Sex Workers Health Communication Capacity Collaborative Health Care Worker Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome People Living With HIV and AIDS Prevention of Mother-to-Child HIV Transmission Social and Behavior Change Communication Tuberculosis United States Agency for International Development



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EXECUTIVE SUMMARY

Social and behavior change communication (SBCC), which uses communication to positively influence the social dimensions of health and well-being, is an important strategy for improving health services at the provider level. With much of the responsibility for providing health care services falling on a cadre of professional health care workers (HCWs), particularly those in lower-level facilities, SBCC strategies targeting this workforce can be an important tool for improving quality of care. To maximize the impact of SBCC activities among HCWs, program designers and implementers must first develop an awareness of factors that improve or impede HCW performance at the facility level. The purpose of this literature review is to identify the facilitators and barriers to HCW service provision in three areas: knowledge and

competency barriers in which HCWs lack the skills and knowledge to provide services; structural and contextual barriers in which systemic and environmental factors affect HCWs ability to provide services; and attitudinal barriers in which attitudes and societal beliefs influence health workers’ willingness to provide services. The research confirms that HCWs experience significant barriers in all three areas, ranging from lack of training and poor management to inadequate equipment to stigma towards certain populations. The findings in this paper can be used to capitalize upon facilitators and anticipate and respond to potential barriers when using SBCC programs to improve the quality of care provided by HCWs.

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INTRODUCTION
The Health Communication Capacity Collaborative (HC3) is a five-year global project funded by the United States Agency for International Development (USAID) designed to strengthen the capacity of middle- and low-income countries to develop and implement state-of-the-art health communication programs. HC3 is led by the Johns Hopkins Center for Communication Programs (CCP) and addresses important health issues such as child survival, family planning, Ebola, HIV/AIDS and Malaria.
As part of its effort to improve health in low resource settings, the HC3 project works to identify strategies to improve the effectiveness of SBCC programs within the context of low- and middle-income countries. Since service providers are critical to improving health in the communities they serve, implementing SBCC programs to influence provider performance is of great importance. In particular, HCWs at lower-level facilities are the frontline providers of essential health services and are often the first resource accessed by people seeking care. HC3 focuses on how to utilize SBCC programs in order to strengthen HCW service provision by developing strategies that identify and respond to changing provider behavior within these contexts.
High quality health care is necessary for people to have a productive and fulfilling life, yet in many lowand middle-income countries health services remain greatly inadequate. The responsibility for providing these services falls largely upon professional HCWs. The term “health care worker” can apply to a wide range of health workers at various levels of the health care system. For the purposes of this paper, a HCW is defined as a worker who has received formal training with a nursing or medical curricula and is a paid employee at a public, private or non-governmental organization health facility. This paper primarily focuses on HCWs based in lower-level or primary care facilities, however, some studies cited in this paper include findings from higher-level facilities within the broader category of the health care system. These papers still present information that is representative of and relevant to the HCW experience.
HCWs are the foundation of the health care system, and they present an important opportunity to use SBCC programs to improve the quality of care across a
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broad spectrum of health services. Many HCWs work within strained health care systems with inadequate resources, workforces and political support. While SBCC programs may have limited influence on health systems as a whole, they do have the potential to mitigate the effects of these challenges through promoting positive behavior change among individual providers. SBCC programs can improve the effectiveness and quality of services through positively influencing the social determinants that influence the HCWs’ work, such as knowledge, attitudes, norms and cultural practices. By identifying and addressing these issues, HCWs can become more competent and conscientious in addressing the needs of their communities.
Within the formal health care system, various factors exist that can either improve or inhibit HCWs’ ability to provide quality care to beneficiaries. Understanding these factors and how HCWs may be influenced by SBCC allows programs to anticipate and respond to barriers through program objectives and design.
HC3 conducted a literature review to identify barriers and facilitators to service provision commonly experienced by HCW programs. Specifically, this paper presents barriers within three categories:
• Knowledge and Competency Barriers–HCWs do not know how to perform assigned tasks.
• Structural and Contextual Barriers–HCWs are not able to perform assigned tasks.
• Attitudinal Barriers–HCWs are not willing to perform assigned tasks.
The purpose of this paper is to serve as a tool to aid SBCC programs in recognizing factors that may potentially influence HCWs, thereby assisting program designers, managers and other stakeholders to better tailor their SBCC programs to meet these challenges. This paper also presents recommendations based on the findings from the literature to guide stakeholders in conceptualizing and designing SBCC programs that can create substantial and sustainable change. While this literature review does seek to identify both facilitators and barriers, the body of available evidence provides more information on challenges faced by HCWs than on factors that increase effectiveness. This paper reflects the findings of the literature and therefore has greater emphasis on barriers to, rather than

facilitators of, effectiveness. Program designers should also keep in mind that these findings and recommendations are based on a broad analysis of

HCWs in multiple countries, and that local contexts should be evaulated and incorporated in the design of specific programs.

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METHODOLOGY

The literature search included peer-reviewed journals on the topic of health care workers (with a particular focus on HCWs’ abilities, performance and attitudes), limited to resources published in the last 10 years, which focused on middle- and lower-income countries. The database search strategy included relevant terms from the controlled vocabularies of

the databases consulted (PubMed, SocINDEX and ERIC)—”health care workers”, “health care providers,” “facility based care,”“health care workforce,”“primary health care,”“clinic worker” and “medical personnel,” supplemented with country terms, thesaurus terms and limits from each database as appropriate.

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KEY FINDINGS
Knowledge and Competency Barriers
Health care workers provide crucial and potentially life-saving services, yet many lack the knowledge and skills necessary to effectively perform the responsibilities they are assigned. Despite substantial efforts and investment, knowledge gaps among HCWs continue to plague the health care sector in many low- and middle-income countries. For example, Dachew & Bifftu found that midwives in Ethiopia had significant knowledge gaps regarding exclusive breastfeeding and duration of breastfeeding (2014). A survey of facility-based HCWs in Ethiopia found significant knowledge gaps, with one third of HCWs having relatively poor knowledge and over half demonstrating unsatisfactory practice on tuberculosis (TB) infection control (Gizaw, Alemu, & Kibret, 2015). A similar study of TB knowledge and practices among health workers in Nigeria and South Africa found similar knowledge deficits (Ibrahim,e et al., 2014; Malangu & Mngomezulu, 2015).
Insufficient pre-service training leads to poor service quality Health care workers are often introduced into the workforce lacking the knowledge and skills necessary to perform their assigned responsibilities. These knowledge and skills gaps are frequently a result of inadequate training prior to entering the workforce. Pre-service training creates the essential foundation for providing quality health services, and training insufficiencies can have a widespread impact on a worker’s capacity to address the needs of the community. An evaluation of barriers to the provision of obstetric care in Ethiopia found that, of the 111 providers surveyed, none had received all components of the basic training on obstetric care, and only 12 percent of providers had received training on any one component of the comprehensive obstetric care training regimen (Austin, et al., 2015). In Pakistan, where certain trainings were found to be contingent upon gender, male physicians were significantly less likely to be trained in Family Planning (Qureshi, 2010). Pressure to replenish a depleted or strained health care workforce can lead to lower-quality training of HCWs. For example, in a study of facility-based maternal and neonatal care in Malawi, Bakker et al. found that a shortage of HCWs due to migration and HIV-related

mortality led to efforts to increase the number of workers through shorter trainings (2011).
Several studies show that providers failed to be adequately trained in the very skills required to perform their assigned tasks (Beltman, et al., 2013; Mwaka, Wabinga, & Mayanja-Kizza, 2013; Esan & Fatusi, 2014). A study in Nigeria found that, of those HCWs whose responsibilities included attending to clients with TB, a majority had only fair to poor knowledge on the concept of direct observation of treatment and the key educational messages to share with the patient during registration for treatment. Thirty percent of these workers had never received training on TB. In Ethiopia, while 89 percent of providers thought that a cervical cancer screening program should be started in their community, 52 percent reported they had inadequate training to screen for the disease (Kress, Sharling, Owen-Smith, Desalegn, Blumberg, & Goedken, 2015). Knowledge gaps extend beyond clinical skills. A study of health facilities in Tanzania found that 81 percent of health workers had never been trained on using their facilities’ Health Management Information Systems and 65 percent could not even properly define it (Nyamtema, 2010). Providing newly trained health workers with the knowledge and skills necessary to administer needed services is fundamental in improving the quality of care.
Insufficient in-service training opportunities compromises care While pre-service training is critically important in establishing a competent health care workforce, regular refresher and in-service education opportunities are necessary to ensure that HCWs have retained and are adhering to earlier training, and are updated on health care advancements. A study in Tanzania found that simply providing reference materials to HCWs did not improve the likelihood of correct dosing of malarial drugs, underscoring the importance of refresher trainings and on-the-job training to cement behavior change (Masanja, et al. 2013).
When carried out properly, in-service training can lead to significant and lasting knowledge gains (Sunguya, Poudel, Mlunde, Urassa, Yasuoka, & Jimba, 2013). An intervention in Uganda to improve obstetric and newborn care coupled a six day refresher training with ongoing supervision and mentoring, learning visits, reviews and dissemination
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activities, which led to knowledge score increases (from 32 percent to 80 percent) a year following the conclusion of the training (Namazzi, et al. 2015). Isolated trainings without any assessment or followup are unlikely to create significant or lasting change in HCWs’ practices (Adams, Olotu, Talkbot, Cronin, Christopher, & Mkomwa, 2014).
Simply providing trainings does not necessarily lead to improved knowledge. Improperly designed trainings and interventions may not only fail to improve knowledge but also occasionally lead to misinformation. For example, efforts to train health workers on new clinical prevention of mother-tochild HIV transmission (PMTCT) guidelines in Tanzania used workshops to train only one person from each site who was then responsible for training their colleagues. These colleague trainings were generally brief and were found to lead to incorrect information being communicated (Shayo, Vaga, Moland, Kamuzora, & Blystad, 2014). A study in Iran comparing the knowledge, attitudes and practices of pharmacists and public health educators regarding oral contraceptive usage found that while pharmacists had a more comprehensive initial training than public health educators, they had a lower level of knowledge in many areas of oral contraceptive usage, side-effects, signs of problems and contraindications than public health educators. The authors speculated that this was perhaps a result of continuing education that was broader in scope in comparison to public health educators who receive more targeted refresher trainings (Sattari, Mokhtari, Jabari, & Mashayekhi, 2013).
Further challenges to in-service training include lack of time to conduct trainings due to high workloads (Bakker et al., 2011) and high worker turnover (Austin, et al., 2015; Kalua, Gichangi, Barassa, Eliah, Lewallen, & Courtright, 2014). Kalua et al. found that a two-year intervention to improve the practical skills of health workers resulted in only very modest improvements. The authors attributed this primarily to the fact that the turnover rate was 75 percent over the course of the two year program, thereby limiting the impact of the training (2014).
Links between improved knowledge and improved practice While improving knowledge through pre-service and in-service training is often the objective of qualityimprovement efforts, research reveals that the impact
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of training-based interventions on actual practice is mixed. Some interventions demonstrate a definite improvement in attitudes and practices following training and education. For example, a literature review conducted by Sunguya, et al. examining in-service nutrition training found that doctors who had received in-service nutrition training were more likely to report improved post-intervention practices in managing child under-nutrition than their counterparts. In Pakistan, family planning training for physicians led to an increase in the amount of time physicians dedicated to family planning care (Qureshi et al., 2010). Similar results linking increased knowledge to better practice and attitudes were found among TB nurses in Lesotho (Malungu & Adebanjo, 2015), health care providers treating Ebola virus (Otu, Ebenso, Okuzu, & Osifo-Dawodu 2016) and adherence to universal precautions among primary health care providers in Pakistan (Yousafzal, Janua, Siddiqui, & Rozi, 2015). Others studies did not find significant association between increases in knowledge through training and improvements in practices (Rockers & Barnighausen, 2013; Masanja, et al. 2013).
While not all research draws conclusions on why increases in knowledge lead to improved practices, some articles attribute success to certain program characteristics. Among the primary HCWs in Pakistan, Yousafzal et al. speculated that better knowledge was associated with improved practices because providers with greater knowledge had both higher perceived benefits from practicing universal precautions, as well as a higher perceived susceptibility to blood-born pathogens in the workplace, both of which motivated better practice. A study among HCWs in Iran similarly found that risk perception was the best predictor of preventative behavioral intention and thus should be an important component of educational programs (ali Morowatishaifabad, Sakhvidi, Gholianvval, Boroujeni, & Alavijeh, 2015).
Other articles attributed performance improvements following training to the trainings’ role within a more comprehensive program design (Irimu, et al., 2014, Masanja, et al., 2013). An intervention in Zambia to improve the quality of PMTCT services improved performance scores from 58 percent to 73 percent through using not only provider training but also following up the training with supportive supervision, detailed performance standards and repeated assessments of service quality (Kim, et al., 2013).

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Factors Impacting The Effectiveness Of Health Care Worker