COMMUNITY HEALTH WORKERS PROFILE, KNOWLEDGE AND EXPERIENCE TOWARDS DEMAND CREATION FOR SKILLED MATERNAL HEALTHCARE SERVICES IN SIAYA COUNTY

Obinge Elizabeth Omondi 1,3 , Fred A. Amimo 1 ,Omondi S. Owino 3 and Asito Stephen Amolo 2 . 1. Department of Public Health, School of Health Sciences, Jaramogi Oginga Odinga University of Science and Technology. 2. Department of Biological Sciences, School of Biological and Physical Sciences, Jaramogi Oginga Odinga University of Science and Technology. 3. Department of Health, County Government of Siaya. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Health systems in many African and Asian countries currently utilize community health workers (CHWs) to deliver community healthcare services and create demand for skilled healthcare services at the health facilities; (Beam & Tessaro, 1994; Bhutta, Lassi, Pariyo, & Huicho, 2010; Haines et al.,2007). Previous findings revealed that knowledge is crucial in service delivery at community level and that coverage of home visits are positively correlated with knowledge levels of lay health workers (Agrawal, 2012). According to WHO 2006, Community health workers (CHWs) have the potential to be part of the solution to the human resource crisis affecting many countries. A study by (Crispin et al., 2012) found out that community health strategy is an effective approach to delivering community-based interventions.
In Kenya, the National Health Sector Strategic Plan 2 (KNHSSP 11) outlined interventions for improving the health indicators in Kenya including community health strategy whose aim was to deliver Kenya essential package of health (KEPH) to the Kenyan population with the community health workers (CHWs) as the main services providers at the community. Although the use of community health workers in Siaya County began after the Alma Ata declaration in 1970s, the engagement was further intensified in 2006 in line with the Kenya National Health Sector Strategic Plan 11 to reverse the poor health indicators in the Country (Ministry of Health Kenya, 2005; Ministry of Health Kenya, 2006). Siaya County being one of the top ten Counties in Kenya with the largest number of maternal deaths (691/100,000 live births) which surpass the Country (KDHS, 2014; MICS4, 2011), has made efforts to invest in community health services as a means to create demand and increase uptake of skilled maternal healthcare services. Moreover, due to shortage of skilled healthcare providers in Siaya County (C. G. o. , CHWs are central in mobilizing communities to engage in health prevention and promotion activities. Owing to the shortage of skilled health care personnel in Siaya County and the desire to increase access to skilled healthcare services, the County Government invested in scaling up community health services in the whole county with a view to increasing access to healthcare services and intensifying demand creation for skilled healthcare services (M. o. H. . However, although some indicators have shown some improvement, utilization of skilled maternal healthcare services have remained low (Department, 2014;UNICEF, 2011). The proportion of mothers attending antenatal visits four times as per WHO recommendation still remain as low as 45% and postnatal care within two days of delivery at 30%. Moreover, unskilled persons attend to about 52% of deliveries by Siaya women (Software, 2014).Therefore as recommended by previous scholars, understanding how socio demographic factors affect CHWs effectiveness is of importance .
The use of community health works in Siaya County began after the Alama ata declaration in 1978. However, after devolution of health services in 2013, the County government of Siaya has invested massively in community health services including payment of honoraria to all the community health workers (Department, 2014) in the county with am aim of enhancing their retention and motivation as recommended in previous reports (Bhattacharyya, Winch, Leban, & Tien, 2001;Glenton et al., 2010;Singh, Negin, Otim, Orach, & Cumming, 2015). It was envisioned that with the provision of the honoraria, the community health workers (CHWs) would be motivated to intensify demand creation for skilled healthcare services, refer pregnant mothers for skilled services and ultimately contribute to reduction of maternal mortality which has not been the case. However, although several trials have shown the efficacy of community health workers (CHWs) in reducing maternal and newborn morbidity and mortality (Bang, Bang, Reddy, Deshmukh, & Baitule, 2005; Tomlinson, 2014), this has not been the case in Siaya County (Software, 2014). The low uptake of skilled maternal healthcare services in Siaya County raises concerns about the implications of CHW efforts to increase demand for skilled maternal healthcare services. Taken together the above observations 602 and the need to identify the bottlenecks hindering the success of demand creation for skilled maternal healthcare services, it was necessary to carry out a study to unveil the dynamics affecting demand creation for skilled maternal health care services in Siaya County. Hence this study aimed at assessing the community health volunteer's profile, knowledge and perception towards demand creation for skilled maternal healthcare services in Siaya County.

Community health services in Kenya
In Kenya, the lay health workers hereby referred to as Community Health Workers (CHWs) are assigned to serve approximately 100 households (approximately 5000 people). They are members of the community identified by the community and trained on basic community health services module to serve the same communities they come from. After the initial training, they are also trained on technical modules based on the context of the intervention that they are assigned to undertake (MOH, 2006). With regard to demand creation for skilled maternal healthcare services, the CHWs are tasked to disseminate key messages to support safe pregnancy & delivery of a healthy new born, advocate for community leadership support for safe pregnancy and delivery of a healthy newborn, promote safe delivery through pregnancy monitoring and timely referral (Ministry of Health , 2006) Statement of the problem:-Studies have shown that community health workers (CHWs) referred to in this study as community health workers (CHWs) are a potential vehicle for creating demand and expanding access to maternal health care services , and With the limited budget allocation for healthcare services in Siaya County, the personnel to serve the health care needs of the population cannot be met and thus it is critical that more cost effective delivery strategies are identified to optimize the use of the available health care services especially skilled maternal healthcare.
Even though Siaya county government has invested in community health workers (CHWs) as a measure to create demand for skilled healthcare services, very minimal gains have been realized with regard to demand creation for skilled maternal health services. It was envisioned that with the provision of the stipend to the CHWs would motivate them to further intensify demand creation for skilled healthcare and ultimately contribute to the reduction of maternal mortality. However, the uptake of skilled maternal healthcare services is still low in Siaya County (Siaya County Annual Performance Report and Plan 2015/16) thus calling for a study to identify the dynamics in demand creation for skilled maternal healthcare services in the county.

Justification of the study:-
Given the shortage of skilled providers in Siaya County, establishing the bottleneck affecting CHWs performance and identification of context specific evidence based strategies to intensify demand creation for skilled maternal healthcare services would go a long way in increasing uptake of maternal healthcare services which will lead to reduction of maternal mortality in Siaya County.
The findings of this study will equip policy makers, stakeholders and program managers with information for designing context specific evidence based intervention to increase utilization of skilled maternal healthcare services in Siaya County.

Research Questions:-
In order to achieve the objectives of this study, the following questions were formulated:

Sample size Determination:-
The sample size was determined using purposive sampling methodology whereby all the 123 CHWs serving within the community units linked to the selected health facility were given chance to participate.

Sampling procedure:-
The study used a multi-stage simple random sampling method to select 123 respondents. The study was part of the baseline survey that was carried out to establish the status of utilization of skilled maternal healthcare services in Siaya County. As such, from a sampling frame of all health facilities per Sub County, the health facilities to be included in the study had been selected. The Community units were then selected on the basis of their link to the eight (8) selected health facilities followed by selection of community health workers (CHWs) from all the selected community units. At least one health provider drawn from the health facilities where the selected community units were linked participated as key informant.
Data Analysis:-Data was cleaned and entered into SPSS version 18 software for analysis. Descriptive statistics were computed and relationships and significant tests determined using Chi square and Odds Ratios (ORs). Statistical tests including independent sample t-test, chi-square test, bivariate and multivariate logistic regression analysis were used to test the association between research variables. Finally, multiple regression analysis was done to identify independent variables that were useful to demand creation for skilled maternal healthcare services. Qualitative data was analyzed using themes and used to back the quantitative data.

Ethical approval:-
The study received approval from Baraton University of Eastern and Central Africa Research and Ethics committee. Another letter allowing the researcher to proceed with the field work was also received from Siaya County Health Research Committee.

Results:-
The data used in this study was drawn from the population of 123 CHWs drawn from 8 community health units linked to 8 public health facilities in Siaya County. 14 Health providers of each facility also formed part of the study population. The sampled respondents were 123 CHWs (n=123) and 14 Health providers (n=14). The return rate from the 14 Health providers' respondents was 100%. Given that the questionnaires were administered personally by the researcher, it was noted that 100% of the questionnaires were appropriately filled while qualitative data were also obtained from the 14 key informants.

Profile of the respondents:-
The first objective of the study was to assess the influence of CHWs profile on demand creation skilled maternal healthcare services in Siaya County. The findings are summarized below. Table 1 shows the percentage distribution of the CHWs respondents.

Age of the CHWs:-
The results showed that the majority of the CHWs totaling to (74.8 %) were aged between 30-49 years each, while only 3.2% of them were aged below 30 years and the rest (10.57%) aged 50 years and above. The above results 604 revealed highly significant (p < 0.05) positive relationship between age of the respondents and the maternal health services provision in Siaya County.
"I think the mature age may be attributed to the fact that younger people still want income to develop themselves and they do shy away from this responsibility and they therefore leave the work to the adults population" (nurse -Akalla health centre)

Sex of the CHWs:-
The exploratory data analysis revealed that more female CHWs (85.37%) took part in the study than their male counterparts (14.63%) giving a gender distribution ratio of about 1:3. "

Marital status of CHWs:-
The descriptive statistics on cross tabulations indicated that the majority of the CHWs in Siaya County are married at 88.62% while1.63% and 9.76% of the respondents are single and widowed respectively. None of the respondents were separated. The results also indicated that female respondents were either married or widow at 85.37% whereas male respondents were either married or single at 14.63%. None of the female CHWs were single. Similarly, none of the male respondents were widow. The results revealed highly significant (p < 0.05) positive relationship between marital status and the maternal health services provision in Siaya County.
"The community members prefer selecting married women or widows who are grounded in the community to volunteer as CHWs because they are rooted in the community" (nurse -Umalla dispensary"

CHWs level of Education:-
The findings presented in table 4.1 established that most of the respondents (CHWs) at 54.5% were at secondary school level of education, followed by those with primary level of education (41.5%), those with tertiary level of education accounted for 4.1%. Moreover, the results revealed highly significant (p < 0.05) positive relationship between level of education and the demand creation for skilled maternal health services in Siaya County.
Sometimes it is difficult to teach the CHWs with education below secondary because most of the training materials are written in English and also the reporting tools are also in English" (nurse -Bondo hospital) The study also sought to establish the number of households covered by the CHWs. This was necessary since it showed the workload experienced by the CHWs in the community. The results showed that majority of the CHWs respondents at 69.92% covered between 101-150 households each followed by 29.27% of the CHWs respondents who covered less than 100 households. Moreover, 0.81% of the CHWs respondents only covered 100 households. The study established whether there is association between household covered and packages delivered to the mothers. The analysis revealed highly significant (p < 0.05) positive relationship between household covered and packages delivered to the mothers.
"Some of our CHWs have too many households that they cannot cover especially on monthly basis and they therefore sometimes avoid households visitations and so they are unable to know when a woman is pregnant until very late" (nurse -Ligala dispensary) "Apart from having too many households to visit, they also have too many tasks to perform in those household making it too difficult for the CHV to manage even though they are willing to do the work" (nurse-Gongo dispensary) 605 .516 -.461 The above independent sample t-test in table 1.2.2 was done to compare demand creation for MHS between the genders of the CHWs. As shown in the table 1.2.1 findings were that the female CHWs had a higher mean of MHS score of 85.4, with a standard deviation of 13.1855 and standard error of 1.4835 than the male CHVs who had a mean of 14.6, with a standard deviation of 10.6759 and standard error of 1.125. Given that the Levene's Test for Equality of Variances was significant (p =.021<.05) we did not assume equal variances, this mean that the variances were significantly different; the assumption of homogeneity of variances was violated. Hence the readings of test statistics was taken from the row labeled Equal variance not assumed, indicating P Value <.05. Therefore the findings of the study indicate that on average the female MHS score (M=85.4, SE=1.4835), was significantly higher than the male MHS score (M= 14.6, SE=1.125), t (119) = 97.262, p = .002. Hence from the results of the study, it was credible to conclude that gender has significant influence on demand creation for MHS in Siaya County.
The married respondents and widowed; (AOR=1.16, 95% CI: 3.21-3.27) and (AOR=1.37, 95% CI: 4.32-2.74)were 1.16 and 1.37 times respectively more likely to create demand for the utilization of maternal healthcare services in Siaya County as compared to the respondents who were single. In addition, the findings established that the respondents whose highest level of education was secondary (AOR=1.12, 95% CI: 4.33-4.58) and those with tertiary level of education (AOR=1.43, 95% CI: 2.87-4.63) were 1.12 and 1.43 times more likely to create demand for the utilization of maternal healthcare services in Siaya County as compared to those respondents whose level of education is primary. Moreover, the findings indicated that the CHWs respondents who covered less than 100 households (AOR=1.65, 95% CI: 1.27-2.60) were 1.65 times more likely to create demand for the utilization of maternal healthcare than those with more households.

Effect of CHWs knowledge on demand creation for skilled maternal health care:-
The second objective of the study was to establish the effect of knowledge on demand creation for skilled maternal healthcare. To address this research objective, questions were carefully developed; the first group were the questions seeking the knowledge of the CHWs and the second were the questions seeking to establish the effect of knowledge on demand creation for skilled maternal healthcare services.

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Knowledge on antenatal, postnatal care and maternal health danger signs;-On the knowledge on maternal health danger signs, the researcher designed questions to collect respondents view on the same. The Knowledge on danger signs was assessed using a question with 9 key danger signs on maternal healthcare. Knowledge scores for individuals were then categorised into adequate if it was equal to or above five, while anything below the five was rated as inadequate.  Table 2 shows that only 30.6% of the CHWs knew when a pregnant mother should start receiving ANC (less than 16 weeks) while the remaining 69.4% did not know the correct timing. Furthermore, the CHWs who knew the exact time (within 48 hours) when a woman should be visited after delivery were 66.7% while the remaining 33.3% were on the opinion of one week and above. Moreover only 30.6% of the CHWs knew when a pregnant mother should start receiving ANC (less than 16 weeks) while the remaining 69.4% did not know the correct timing. Interestingly, the study also revealed that only 31.7% of the CHWs had adequate knowledge of the maternal health danger signs while 68.3% had inadequate knowledge of the danger signs.

"The CHWs do not have adequate knowledge on maternal health although when they come to the health facility we do try to teach them" (nurse -Umala dispensary"
Trainings attended by CHVs:-All CHWs are required to undergo a basic training on community health strategy before being engaged in demand creation activities. The findings of this study however established that even though all the CHVs were expected to create demand for skilled maternal healthcare services, only 101 out of 123 had undergone the training. In order to establish whether the basic community health strategy has influence on demand creation for skilled maternal healthcare services, a multivariate analysis was done. The results revealed highly significant (p < 0.05) between the CHV's attendance of trainings and demand creation for skilled maternal health services in Siaya County.
Effect of training attended on demand creation for skilled maternal healthcare services:-  Consistent with previous studies, the above findings also showed that for CHWs to be effective, they need to be properly trained in whatever intervention they are to implement, (

CHWs experience in demand creation for skilled maternal healthcare services:-
The third objective of the study was to establish the CHWs experience on demand creation for skilled maternal healthcare.  Contrary to findings by (Crispin et al., 2012) that CHWs with lower literacy levels were able to satisfy and enable their clients effectively ; this study found out that compared to CHWs with lower literacy levels, those with higher level of education performed better. The findings on influence of workload on demand creation also conform to previous studies which indicated that for CHWs to be effective, they should cover certain optimal population size with an optimal range of services ( (Kasl & Cobb, 2002), exposure to factors that prompt action and confidence in their ability to successfully perform an action influences peoples decisions and therefore the fact that the majority of the CHWs had inadequate knowledge on maternal health clearly indicates that they are also unable to coerce women to take up some important decisions on why skilled maternal health care is important.

CHWs experience in demand creation for skilled maternal healthcare services:-
The above findings also established that there were no schedules for facility visits and therefore each CHV decided individually on when to make a visit. Although 57.7% and 8.1% visited the health facility weekly and monthly respectively, the remaining 31.7% and 2.4% visited the health facility whenever necessary or quarterly respectively. The results on frequency of contact with the facility have revealed highly significant (p < 0.05) positive relationship between frequency of facility visits and demand creation for skilled maternal health care services.
According to the above findings, it emerged that inadequate resource such as commodities is the greatest challenge faced by CHWs working with health providers at the link health facility. This was backed up by 82.1% of the CHWs respondents. Moreover, inadequate staff (79.7%) and negative staff attitude (77.2%) were also challenges faced by CHWs. Furthermore, lack of technical support was cited by 65.9% of the respondents while lack of recognition was cited by 63.4% of the CHWs. However, inadequate meetings was the least cited by 49.6% of the respondents In addition, the results has established significant (p < 0.05) positive relationship between the challenges faced by CHWs working with health providers at the link health facility and demand creation for skilled maternal health care services.
Although it is well stated in the community health services manual that CHWs should use referral notes, the findings of this study showed that there was no uniformity in ways in which CHWS do referrals for maternal health care services with only a small percentage using the recommended referral notes (10.6%) while the rest either accompanying the client (68.3%) or using verbal referral (87.8%). Moreover, there was a significant (p < 0.05) positive relationship between the ways in which CHWS make referrals for maternal health care services and demand creation for skilled maternal health care services.

Conclusion:-
The findings of this study have shown very strong positive association between Knowledge, households covered (workload), CHWs practice and demand creation for skilled maternal healthcare services in Siaya County. In view of the above findings, strategies to increase demand creation for skilled maternal healthcare services are a priority for Siaya County. While initial basic training of CHWs on community health strategy may address the anticipated demand creation activities, over time the increasing scope of activities and tasks assigned to CHWs may lead to gaps in knowledge and incompetency in delivering specified tasks such as demand creation for skilled maternal 611 healthcare services. Therefore investment in ongoing training of CHWs in maternal health coupled with periodic mentorship and evidence based performance monitoring both at the health facility and the community would go along way in ensuring that CHWs have adequate knowledge and conform to set standards of practice while creating demand for skilled maternal healthcare services in Siaya County.
The evidence gathered by this study also suggests that individual work load has implication on performance and therefore reviewing the nature and workload of CHWs and instituting evidence based mechanisms for monitoring CHWs performance at household level would enhance their effectiveness in demand creation for skilled maternal healthcare services. The findings have implications on context specific evidence based programming for maternal health care in Siaya County and highlight the need for adopting multiple context specific interventions if utilization of skilled maternal healthcare services is to be optimized in Siaya County.