Factors Affecting the Use of Job Aid Posters as a Guide for Malaria Diagnosis among Primary Healthcare Workers in Ibadan, Oyo State, Nigeria

Introduction: Malaria is the major cause of mortality worldwide. Accurate diagnosis is key for effective management of the disease. Non-adherence to diagnosis guidelines by primary healthcare (PHC) workers affects quality healthcare provisions. Job aid posters help enhance adherence to guidelines for several diseases. Thus, this study determined PHC worker’s use of job aid posters and identified factors affecting its use as a guide for malaria diagnosis. Methods: The study was a hospital-based cross-sectional survey, a multistage sampling technique was used to select 384 PHC workers from seventy-eight PHC facilities in Ibadan Oyo State, Nigeria. A semi-structured, self-administered questionnaire was used to obtain participant’s socio-demographic characteristics, knowledge and adherence to malaria diagnosis guidelines, and factors affecting the use of job aid posters as a guide for malaria diagnosis. Data analysis was done using descriptive statistics, chi-square, and logistic regression with P-Value=0.05 declared as statistically significant. Results: Two hundred and forty-four (63.5%) PHC workers were knowledgeable about malaria diagnosis guidelines whereas only 58.1% of the total respondents adhere to the guidelines. Just less than half (45.3%) of participants uses job aid posters always. Knowledge of malaria diagnosis guidelines (AOR = 0.272, 95% C.I = 0.115-0.643), comprehensiveness of job aid poster (AOR = 0.345, 95% C.I = 0.148-0.807), physical integrity of job aid posters (AOR = 0.219, 95% C.I = 0.092-0.522), and positioning of job aid posters (AOR = 5.704, 95% C.I = 2.375-13.67) were significant predictors of use of job aid posters for malaria diagnosis. Conclusion: the healthcare worker’s adherence to guidelines for malaria diagnosis was inadequate. Provision of comprehensive job aid posters on malaria diagnosis, replacement of damaged ones, and strategic display of the job aid posters is recommended to enhance use and adherence.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral design to mitigate discontinuation of injectable contraceptives. Methods: We applied behavioral economics insights to mitigate the discontinuation of injectable contraceptives. This process created an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. A stratified-pair cluster-randomized field trial tested the effectiveness of the intervention. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods, adjusted for study design, participants’ backgrounds, and contextual factors, estimated the intervention’s effect on discontinuation rates. Results: A behavioral design methodology was feasibly implemented in a rural, low-resource setting in Ethiopia. The resultant intervention package was successfully delivered in 19 satellite health posts in four districts. Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. The injectable discontinuation rate was 10.8 % (95% confidence interval: 2.2, 19.3) points lower in the intervention area compared to the control area during the post-intervention follow-up survey. Conclusion: The use of two tools informed by behavioral economics —the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics insights and the behavioral design methodology have the potential to enhance family planning programs in Ethiopia and elsewhere.

Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial

Background: Contraceptive prevalence in Ethiopia jumped from 6% in 2000 to 36% in 2016, mainly due to increased injectable method use. However, discontinuation rates among injectable users were high (38%). Given that the public sector is the major source for injectable contraceptives, John Snow Inc. (JSI) in collaboration with ideas42 worked with Ethiopia’s flagship Health Extension Program to apply behavioral economics informed approaches to mitigate discontinuation of injectable contraceptives. Methods: Behavioral diagnosis was conducted to identify the primary drivers of discontinuation of injectable contraceptives. Using these insights, a user-centered behavioral design approach was implemented to create an intervention package, consisting of a health worker planning calendar, a client counseling job aid, and client appointment cards. The study area included two districts from the four regions where JSI was implementing a family planning program. One district from each region was randomly allocated to the intervention arm. Women visiting health posts to use injectable contraceptives were enrolled in the study. Regression methods adjusted for study design, participants’ backgrounds, and contextual factors, were used to estimate the intervention’s effect on discontinuation rates. Results: Intervention adherence was high for the appointment cards and counseling job aid, but not for the planning calendar. This was not surprising as using appointment cards and the job aid was within the routine workflow of health extension workers, but using the planner was not. The injectable discontinuation rate was 10.8 % points lower in the intervention area compared to the control area during the post intervention follow-up survey. Conclusion: The use of two behavioral economics informed tools—the appointment card and counseling job aid—effectively decreased injectable discontinuation even with the presence of other health system bottlenecks. Behavioral economics approaches have the potential to enhance family planning programs in Ethiopia and elsewhere. Trial registration: ISRCTN ISRCTN17390653 (10/04/2019)

Addressing Barriers to Exclusive Breastfeeding in Mozambique: Opportunities to Strengthen Provider Counseling and Use of a Job Aid (OR30-03-19)

Objectives The objectives of this implementation science study are to 1) identify problems and challenges with exclusive breastfeeding (EBF) experienced by mothers in Nampula, Mozambique, 2) gain an understanding of the quality and type of counseling on breastfeeding problems and challenges provided by facility and community-based health providers and 3) assess the use of a job aid to improve the identification of and counseling on barriers to EBF within existing health services. Methods In-depth interviews were carried out with mother-child pairs (n = 23) who ‘ever breastfed’ and had infants less than 6 months of age, as well as facility-based (n = 13), and community-based health providers (n = 10) who offered maternal, child health and/or nutrition services. Observations of breastfeeding counseling were also conducted with mothers. Following these interviews and observations, the research team and program implementers jointly developed provider job aids addressing breastfeeding challenges, which were used in training facility and community-based health providers in two districts, designated study areas. Following two months of implementation within routine health services, providers and mothers were interviewed regarding their experiences. A qualitative analysis was conducted. Results Difficulty latching, and engorgement were barriers to delayed initiation of breastfeeding, and perceptions of insufficient breastmilk and early return to fieldwork were challenges in maintaining EBF. Community providers referred women with breastfeeding problems to health facilities, yet lacked training and knowledge to provide basic breastfeeding support. Facility-based providers demonstrated some knowledge in identifying breastfeeding difficulties, yet often lacked the ability to counsel on common breastfeeding problems. The job aid was found to be useful for most providers. Conclusions This study revealed the need to strengthen counseling skills among health providers to address challenges experienced with EBF. Job aids, in tandem with adequate training and practical experience and/or case studies may equip providers to improve lactation support at the facility and community level in low and middle-income countries. Funding Sources United States Agency for International Development (USAID).