Date of Award

2018

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

College of Nursing

First Advisor

Susan D. Newman

Second Advisor

Lynne S. Nemeth

Third Advisor

Larry Sthreshley

Fourth Advisor

Peter Johnson

Abstract

Purpose: The purpose of this dissertation is to explore strategies to improve maternal and newborn health workers’ clinical competence and performance, particularly among nurses and midwives, in low-and middle-income countries (LMICs), through innovative continuing educational approaches using priority evidence-based content. A feasibility trial with one such learning approach was implemented with maternal and newborn health providers in a hard-to-reach setting of the Democratic Republic of the Congo (DRC) in order to test one possible response to the continued high maternal and neonatal mortality in that country. The study contributes to the knowledge base on provision of critical continuing education to maternal and newborn health workers in hard-to-reach settings and to the global effort underway to address excess maternal and neonatal mortality in LMICs. Problems/Aims: Health worker clinical performance is often inadequate in developing countries. Substandard delivery and emergency obstetric care (EmOC) in health facilities has been widely documented as a major cause of maternal mortality in health facilities globally. Similarly, studies show that quality gaps are leading to higher rates of neonatal mortality in facility births. A basic strategy for improving health worker practice and strengthening clinical performance is through the promotion of continuing education (CE). However, there are many challenges to organizing CE opportunities for healthcare workers in hard-to-reach LMIC settings. The aims of this research were 1) to explore potential approaches to continuing education for maternal and newborn health workers in LMICs by examining the approaches that are currently available worldwide and 2) evaluating one concrete approach using a mobile phone mLearning app. We examined the feasibility and acceptability of the use of mLearning with facility-based maternal and neonatal health workers in one hard-to-reach setting of the DRC. We also evaluated the use of mLearning for a preliminary impact on facility-based health worker Basic Emergency Obstetric & Neonatal Care (BEmONC) self-confidence and clinical knowledge, and on select maternal and newborn outcome trends (as a proxy for evaluating improved health worker clinical behavior/performance). We also sought to refine intervention delivery in the DRC and strengthen study procedures required to conduct a robust future largescale trial. Design including theoretical basis: This study design is comprised of two literature reviews on the topic and a feasibility study using a convergent parallel mixed methods and community-engaged pilot cluster-randomized trial design. Our theoretical basis is comprised of complementary theoretical approaches: (1) Benjamin Bloom’s Theory of Mastery-Learning and Taxonomy of Educational Objectives; (2) Kirkpatrick’s Model of training evaluation; and (3) The Theoretical Domains Framework (TDF). Findings: Our literature reviews on CE approaches for facility-based maternal and newborn health workers in low-income countries revealed that conventional and simulation training using varied teaching methodologies can improve provider knowledge, skills, clinical practice, and patient outcomes. However, results are variable and there is limited evidence overall, with minimal use of robust study designs and validated measurement instruments, that document the association between CE and long-term effectiveness of the interventions with improved patient outcomes. Other creative interventions are being piloted in eHealth / eLearning including mobile phone learning applications (mLearning) and these have shown encouraging results in overcoming some key challenges in providing health workers with evidence-based learning in more remote settings. mLearning was found to be feasible and acceptable to health workers and key stakeholders in the DRC. A trial of one recent mLearning evidence-based app, the Safe Delivery App, increased health worker knowledge and self-confidence on the management of obstetric and newborn emergencies 3 months after introduction and indicated preliminary encouraging impacts on health workers’ practices in BEmONC. Conclusion: eLearning and mLearning show promise for improving maternal and newborn health worker practice and reducing mortality in low-and middle-income countries, particularly for health workers in more remote settings, where the challenge of maternal and neonatal mortality and quality assurance of emergency obstetric and neonatal care is greatest. Factors such as health worker motivation and self-efficacy, as well as the physical and policy environment, emphasized by Bloom and the TDF, are essential in improving practice and should be considered, along with cost, in designing scalable and comprehensive maternal and neonatal mortality programs for improved outcomes.

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