Study design
The study employed a descriptive cross-sectional design.
Setting
The study was carried out in three selected districts of Tigray region, Ethiopia; namely Kilte Awlaelo, Saesi Tsadamba, and Degua Temben districts. Tigray is the most northern regional state of Ethiopia. The total population of the region was 4.6 million in 2010[20].
The Ethiopian health system is a four-level health system, characterized by the lowest level called a primary health care unit, comprising one health center and five satellite health posts, and then the district hospital, zonal hospital, and specialized hospital[12]. Health centers are staffed with a health professionals’ team, including midlevel health professionals, for instance, health officers, nurses, midwives, sanitarians, and laboratory technicians. Ideally, there are five satellite health posts under one health center which means one health center supervises and receives referrals from five satellite health posts. Health posts are the operational units for HEWs.
Participants and sampling
Since all HEWs and health posts in the three selected districts were eligible for the study, we did not use any specific sampling technique. Rather, the focus was at ensuring participation of as many HEWs as possible. To do this we had the list of all kebeles in the districts and HEWs working in each kebele. A kebele is the smallest administrative unit in Ethiopia. It is synonymous with a village which has an average population of 5,000 people. After getting permission from Tigray regional health bureau to undertake the study, the data were then collected by travelling to each kebele to meet the HEWs for an interview.
Data collection
Initially a semi-structured interview type questionnaire on paper was prepared by reviewing guidelines and manuals for HEWs. The questionnaire was divided into four sections. Section 1 was on the bio-data and characteristics of HEWs. Section 2 dealt with the availability of supplies, facilities, and logistics at health posts for maternal health care. This availability of supplies, facilities, and logistics was confirmed by observation. Section 3 was about knowledge and performance of HEWs on contents of antenatal care, birth assistance, danger symptoms, danger signs, and complications in pregnancy and making referrals. Section 4 was about barriers and facilitators for HEWs in maternal health services provision.
This hard copy questionnaire was then converted to an online questionnaire using software called Episurveyor and downloaded to a mobile phone (Nokia E71)[21]. Episurveyor is a web-based system which allows users to create a questionnaire online, download the questionnaire to a mobile phone, fill out the questionnaire using the phone, send it to a server, view data online, and export data into statistical software for further analysis. Downloading an online created questionnaire on a mobile phone was possible directly through an internet connection at the mobile phone or downloading the online questionnaire first to a personal computer (PC) and then transferring it to a phone using Universal Serial Bus (USB). All the data collected can also be saved in the memory of the mobile phone and backed up to a remote server, where it can be analyzed later.
Prior to the actual data collection, the online questionnaire downloaded on the mobile phone and using mobile phone for interview were pre-tested. The pre-test was done to assess clarity of the questions, time needed to finish the interview, and to know respondents’ comfort to be interviewed using a questionnaire on a mobile phone. This pre-test was done by interviewing five HEWs who were not included in the actual study. One major finding of the pre-test was that few of the questions had a long list of options and were found to be time-consuming when asked using mobile phones. The interviewer had to scroll down and up several times to fill out the responses of respondents. Hence, we decided to exclude these few questions from the online questionnaire and included them on paper instead. All the interviews were conducted by the principal investigator. We chose the principal investigator; because new data collectors may not have been familiar with the mobile phone approach of data collection, and we had an interest to understand very well whether mobile phone data collection can be feasible for subsequent studies in the Ethiopian context.
Data analysis
The collected data which was submitted to the database server was exported to SPSS version 16 (SPSS Inc, Chicago, IL, USA) for analysis. Descriptive statistics was used to summarize the data and the results were presented using frequency tables and percentages. To assess the knowledge of HEWs on contents of antenatal care counseling, danger symptoms, danger signs, and complications in pregnancy, relevant questions from the questionnaire had weights attached to them to create a composite score of knowledge. For the knowledge on contents of antenatal care counseling service, the maximum score was 25 points and points were awarded on a discrete (whole number) rather than a continuous scale, based on the number of positive responses. Interpretation of scores was based on the Ethiopian university education scoring system. We used this scoring system, because we could not find a standard scoring system for evaluating the HEWs’ knowledge. Hence, we used the Ethiopian university scoring system by slightly modifying it into a four-scale ranking. Respondents whose scores were 80% or more were classified as having excellent knowledge on contents of antenatal care counseling; those who scored between 60% and 79% were classified to have good knowledge; those who scored between 45% and 60% were classified to have fair knowledge; and those who scored 45% and below were classified as having poor knowledge. We slightly modified the Ethiopian university scoring system into a four-scale ranking for convenience because the Ethiopian scoring system has a long list of levels. A similar approach was used to interpret the knowledge of HEWs on danger symptoms, danger signs, and complications in pregnancy. Additional interpretations of scores were also made using the mean values of respondents’ knowledge. The mean and median values for the knowledge scores were virtually the same.
Ethical consideration
The study was approved by an ethical review committee at the Tigray regional health bureau in Ethiopia. The purpose of the study and the use of mobile phones were explained to each respondent. A verbal consent to participate in the study was obtained from each respondent. Participants were also informed about their right to withdraw from the study at any time of the data collection if they felt any discomfort.