This section includes a descriptive summary on the baseline survey and the qualitative study (focus group discussions and individual interviews), a summarised table of results for the three phases in the development of the intervention and an elaborate presentation of the findings from the fidelity data and reflections from stakeholders.
1. Background description of respondents
Baseline survey
Table 1 presents demographic characteristics of respondents. Most of respondents were female (98%), and the majority ranged between 20 and 39 years of age (85%). More than half of respondents (72%) had little to no education and a little over half (54%) were employed. Almost a quarter (38%) reported that they had some kind of illness or long-term disability.
Table 1
Background characteristics of survey respondents (N = 1234)
CHARACTERISTICS
|
|
|
EJISU-JUABEN (N = 631)
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KWABRE (N = 598)
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AGE *
15–19
20–29
30–39
40–49
50–59
60–69
|
4.1
39.8
42.8
11.2
1.1
1.0
|
3.7
46.3
40.6
8.5
0.5
0.3
|
SAMPLE
|
EJISU-JUABEN (635)
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KWABRE (599)
|
EDUCATION
≤ 9 years
12 years
≥ 12 years
|
65.8
20.7
3.5
|
79.6
19.0
1.4
|
EMPLOYMENT
Employed
Unemployed
Retired
|
56.6
39.8
3.6
|
52.4
41.1
6.5
|
GENDER
Female
Male
|
97.3
2.7
|
97.8
2.2
|
LIVING ALONE
Yes
No
|
29.8
70.2
|
20.0
80.0
|
LONG TERM ILLNESS
Chronic
Non-chronic
None
|
9.6
34.5
55.9
|
9.0
22.5
68.5
|
LANGUAGE
Local language
English
|
90.1
9.9
|
88.7
11.3
|
Note* Sample size for age is less than other characteristics because some of the reported ages were either too low or too high. |
Qualitative study respondents
Focus group discussions
The mothers in this study were petty farm product traders aged between 20 and 45 years with different educational backgrounds from little or no education to tertiary-level education.
Four (4) mothers were married and one was divorced but co-habiting with a new partner; the
number of children for each woman ranged between 1 and 4.
The community health nurses included four (4) females and one male with an age range between 28 and 36 years. Seniority among community health nurses ranged between three (3) and nine (9) years.
The community-based agents in the study had other occupations: three were farmers, one was a teacher and one was a trader. The age range for the community-based agents was wide, 30–72 years, and out of the five (5), three (3) were females and two males.
Individual interviews
All three administrators: the health director, the disease control officer and the health promotion officer, had long experience in their functions, with at least eight years of experience in health systems management (8). The director and health promotion officer were both women.
In summary, the baseline survey, together with the focus group discussions, interviews, observations and discussions resulted in the need to design an interactive health literacy intervention to address understanding health information, navigating the health system and having health provider support for caregivers. The child welfare clinics were recommended as suitable setting for this intervention. Details of the findings can be found in Table 2.
Table 2
Summary of results from the application of the 3-stage framework for co-production and prototyping of game and brochures
Activity
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Stakeholders
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Objectives
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Results
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Stage1: Needs assessment
Survey
Stakeholder consultation
Focus group discussions
Individual interviews
Observations at Clinics
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• Caregivers with children under 5 years
• Research assistants
• Researchers
• Mothers
• Community health nurses
• Community- based agents (volunteers)
• Research assistants
• District health directorate staff
• Researchers
• Mothers
• Community- based agents
• Community health nurses
• District health promotion officer
• District disease control officer
• District health director
• Mothers at child welfare clinics
• Community health nurses
• Researchers
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• Assess health literacy needs and challenges in malaria management in the community
• Brainstorm on possible intervention concept based on findings from survey
• Assess perceptions on community case management of malaria with focus on health literacy
• Gain insight on existing malaria community programmes, challenges and strengths
• Observe activities at child welfare clinics
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• Out of the nine dimensions, three scales were selected based on the average mean score. Scale 1 Having Health Provider Support (2.44); Scale 7 Navigating Health System (3.33) and; Scale 9 Understanding Health Information (3.35).
• On the management of malaria, 96% of caregivers had knowledge on the main symptom of malaria (fever); 23% ; 47% of caregivers had children with recent episode of malaria and their treatment sources included 69% self-treatment; 31% hospital treatment and 0.3% did nothing as their first response to the disease. Most important challenge identified was seeking the right treatment source.
• Identified child welfare clinic as the suitable setting for the intervention
“I think if we include the programme and volunteers on the Community Health Nurses weighing sessions and reach out to and educate mothers on the programme it will be successful.” (Community health nurse)
• Perceptions on existing malaria programmes were grouped into five themes:
• 1) Mothers valued the programmes due to possibility of education; “I was involved in the malaria programme because of my work as a prophetess (a religious female leader). People in the community do come to me with all kinds of sickness, so I thought it wise to involve myself to get the chance to be educated and to educate other people in the community in sleeping in the mosquito nets”.
2) Nudging and reaching out through existing social platforms to promote healthy practices; “I’ve heard about the malaria programme because even last year, they came to share mosquito nets to us”.
3)Health education presented as instruction; “Some of the mothers did not follow the instructions that was giving to us. They were supposed to dry the net in the sun before sleeping in but some of the mothers didn’t follow the instruction and there were complaints of facial itching.”
4) Strong agency of mothers willing to support peers to understand and use health information; “I and other mothers were also doing the sweeping of the venue every morning and evening to enhance or facilitate the sharing of the mosquito nets. We also saw it wise to come together to educate ourselves and other mothers in the community to prevent malaria”.
5)Possible cultural barriers for health promotion.
Recommendation on future intervention was focused on interactive health education during social gathering like the child welfare clinic; inclusion of community health volunteers with incentives.
• The health administrators shared that: 1)the community case malaria programme has been put on hold for the past 2 years due to logistics on medical supply; “they brought the medicine for them to use and after the medicine was finished, that was the end of the programme, they did not receive any thing for the treatment, the challenges had to deal with the logistics that were never supplied.” Health administrator1
2) Social gatherings like churches or child welfare clinics appropriate for malaria programmes; “I think for a health literacy programme, we have to use the community health nurses, because you know the mothers will bring their children for weigh-in if nothing at all, for immunization.” Health administrator 2
3)Non-functional but existing mother support groups and;
4)Possible use of social media applications for health education.
• During the visit to 3 clinics we observed that: 1)two nurses facilitated activities with support of community health volunteers at each site; 2)Activities included those outlined in the UNICEF checklist but they were not in the same order as the checklist; 3) Each site started with health education and; 4) Long waiting time for mothers.
We planned to engage mothers in the game play while waiting. In addition, we plan to use brochures during the health education sessions.
• Mothers seemed to have knowledge of the proposed board game and found it interesting; “Are you referring to Ludo’s snakes and ladders? I don’t know if it will work, (giggles) but I like the game and it sounds like an interesting idea”. (Mother at CWC).
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Stage 2: Co-production of materials
Stakeholder consultations for
game co-design
Brochure design
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• Communication design researcher
• Mothers
• District health directorate
• Researchers
• Health Resource and Learning Unit, GHS
• District health directorate
• Researchers
|
• To design a game useful for caregivers to manage malaria and suitable for use at the clinic
• Design of brochures was useful, promoted interaction and was easy for caregivers to understand
|
• Consultations with communication design researcher on an iterative approach to adhere to principles of co-designing.
• Formative evaluation in process of design and summative evaluation from other stakeholders.
• Discussions on ideas and creation of mind maps based on objective intervention resulted in draft layout, colour schemes, graphic elements, rules for game play and identification of materials to develop the game.
• The flat panel game comprised one hundred (100) squares in a ten by ten grid, shaded in colours of white, yellow, red, green and blue. Questions and answers to be used in the board game were designed as colour coded flash cards for participants. In total, 56 questions and answers were categorised under causes, symptoms, treatment and prevention of malaria.
• This study used three brochures for health education. Researchers engaged with the health resource learning unit of the Ghana Health Service to develop the malaria brochure.
• By theory and discussions on layout, the team developed a brochure with precise messages, picture for each topic on malaria with an appealing and welcoming cover.
• Front page was captioned as “Avoid malaria, keep your child healthy and happy” displayed together with a picture of a happy mother and her baby. This was deliberate to attract users.
• Brochure on breastfeeding was retrieved from the UNICEF website and restructured to meet the objective of the intervention (not lengthy text, more pictures).
• The brochure on navigation of health system outlined the levels of healthcare options for seeking appropriate care. It showed a bottom-up approach which begins from community health volunteers, through the CHPS compounds and mapped up to the tertiary hospital accessible in the district.
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Stage 3. Prototype of game and brochures
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• Mothers
• Community health nurses
• District health directorate
• Research assistants
• Researchers
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• Assess feasibility of game and brochures
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• Finalized on the drafts for the game (mosquitoes and ladders) and brochures.
• Stakeholders, including a mother played the game to assess its feasibility; this resulted in some changes to the rules and rephrasing of some questions.
• This session addressed the need to translate all questions to the local language and present both languages to avoid misinterpretations.
• Training of community health nurses in the use of these materials and with role play sessions useful to assess feasibility. These sessions added the need to clarify some questions and responses and further rephrasing of other questions.
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2. Development of board game and brochures
Several simulations of the game play and versions of the brochures allowed the researchers and stakeholders to better understand how learners would interact with these materials as well as with other participants. The final versions of the board game were designed using a vector graphics software to ensure high-quality output and the ability to make changes after feedback from stakeholders. Finally, the board game with questions and answers were printed on card and laminated to prevent degrading of printed ink and wear out of the paper material during use. Brochures were as printed and packaged to avoid wear and tear as well as misplacement.
3. Fidelity Assessment
The pilot covered a six-month period from August 2018 to February 2019 in the 10 selected communities. Below, the observations by the research assistants on the fidelity of the intervention are shown.
Table 3
Intervention Fidelity Assessment: Compliance with intervention implementation design (N = 101 clinic visits)
Item
|
Intervention Fidelity Assessment (101 respondents)
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Yes %
|
No %
|
1
|
Did community health nurses give a recap of previous months’ sessions?
|
85.1
|
14.9
|
2
|
Was the first hour of the day’s session covered by brochure discussions and game play?
|
83.2
|
16.8
|
3
|
Was the brochure discussion held before the game discussion?
|
91.1
|
8.9
|
4
|
Did all caregivers present have brochures for discussions?
|
87.1
|
12.9
|
5
|
Did the Community Health Nurse engage mothers during the discussions?
|
93.1
|
6.9
|
6
|
Did caregivers participate in the brochure and game discussions?
|
94.1
|
5.9
|
7
|
Were caregivers given time for questions with feedback?
|
92.1
|
7.9
|
8
|
Was the game played in groups?
|
87.1
|
12.9
|
9
|
Did community health nurses explain the rules of the game to caregivers?
|
86.1
|
13.9
|
10
|
Did the community health nurses facilitate the game discussions?
|
81.2
|
18.8
|
11
|
Did the game lead to further interactions with or questions to community health nurse?
|
86.1
|
13.9
|
12
|
Did the community health nurse use the platform to elaborate further on the questions and answers to the caregivers?
|
86.1
|
13.9
|
13
|
Were caregivers interested in the game?
|
86.1
|
13.9
|
14
|
Did the game promote group interaction?
|
89.1
|
10.9
|
15
|
Did the community health nurses refer to illustrations and pictures in the brochure in the discussions?
|
79.2
|
20.8
|
16
|
Did the facilitator introduce the topic for the next discussions session to caregivers?
|
82.2
|
17.8
|
The table shows sixteen (16) steps outlined in the intervention manual for the intervention delivery and whether research assistants could observe them as planned. The percentages were based on a “yes or no” response. For all items, at least 79% of the observations showed that the intervention was carried out as planned. The least carried out activity concerned brochure illustrations, which meant that in 21 out of the 101 observations carried out, the CHNs did not go through the brochure illustrations with caregivers as expected. However, 90% of observations showed that the game was interactive, and participation and interest was high in the intervention as observed.
4. Stakeholder reflections on intervention development
The following summary describes reflections by some stakeholders based on their involvement in the design and roll out of the intervention in the pilot phase. These interviews were pre-coded with the themes on the advantages of adapting co-creation in the design of the intervention. The summary here does not touch on effectiveness as it did not result in any quantified outcomes. The themes included usefulness, ownership and sustainability of the intervention.
4.1 Usefulness of intervention
The intervention resulted in producing health education materials with messages that were easy to understand and promoted a good relationship among caregivers and their healthcare providers.
I. Usefulness of intervention (local needs driven)
The co-creation process of developing the intervention and the adaption of the Ophelia approach to develop an intervention based on local needs led to a useful intervention among the users. The relevance of this intervention lies in the materials developed based on needs and the intervention delivery approach adopted. When asked whether the intervention was local needs driven, one stakeholder said:
“I think it was 100%. It was because the issue that we are talking about relates to mothers in Ghana. Issues on malaria, breastfeeding and visiting the nearest hospital as first facility to seek health care. So, it was tailored to mothers in Ghana”. Research assistant
“This has been reflective of our lives. We are grateful to be partakers in this programme”. Mother
These quotes suggest that the intervention matched the needs of caregivers as identified through the needs assessment with the second quote showing a mother’s content with the relevance of the intervention in her life.
II. Useful content of materials for health education
In relation to the content, the health information helped to debunk some perceptions on treatment of malaria and inappropriate health seeking behaviours:
“During this intervention, we were able to clear so many fallacies on malaria, for example the perception that every fever is malaria”. Then some of them came to realise that; so, when my child has fever that does not mean he or she has malaria. It could be due to other reasons, so I have to take him or her to the hospital to have some tests taken to confirm whether it is malaria or something else troubling my child”. Nurse
“I think it is a good game because there were things I didn't know about using mosquito nets, like, how long a mosquito net should be used before treatment but now through the game I do”. Mother
“The game is educative. I have learned that you should visit the hospital when you have malaria and not buy drugs from drug or chemical shops”. Mother
From the quotes above, the content of the materials used in the game and brochures helped to change wrong attitudes among some mothers on management of malaria in children under five years. In the first quote, mothers’ perception on treating every fever as malaria was addressed based on the content of the brochures and games. Thus, the content of the materials was useful in addressing mismanagement of malaria in children under five years.
III. Useful communication tools for understanding health information
In this intervention, both English and the local language (Asante-Twi) were used especially for the question and answer cards for the game to make it easy to read even for people with low literacy levels. The use of precise and simple sentences together with the illustrations in the brochures made it easy to communicate and interact with the caregivers.
“It was very simple for them to understand with guidance; they (researchers) didn’t use jargon they (mothers) did not understand. They (researchers) used everyday things which mothers were familiar with, so for me I will recommend it to others”. Health directorate representative
“I have learned a lot about the things to do to prevent malaria; like the man weeding on the ludu (game) which tells me that when I weed around my house it can prevent mosquitoes from breeding”. Mother
The above quotes show how simple sentences with illustrations in the brochures and the game made it easy to understand the information and set the pace for interactions. The use of the brochures resulted in efficient discussions because mothers could see visually the things being discussed in the brochures.
“… most of our weighing, we don’t get those things we only go and deliver our message with our mouth. What we have written, we only go and deliver it to them. But this time, there is something that we have, the person has, I also have so we are all looking through it together. Whatever we need to discuss, there is an illustration, one could ask, oh madam this one, what does it mean?” Nurse
This quote adds to the usefulness of the brochure in health education sessions at the child welfare clinics through the illustrations and by providing a tool to improve discussions.
IV. Intervention approach and health provider support
The interactive nature of the intervention changed perceptions on the role of health providers among both health providers and caregivers. As a community health nurse describes:
“We need to interact with them, consult them and know, what is happening with them, because through this some of them were able to come out with what their problems are. Initially they would think that the nurse is only interested in weighing my child and know how heavy he or she is, and that is it. But now we are teaching something different so when the person has a problem, she can come to you oh madam, this and that is what is happening to me and so what could I do? And then the advice that you have you can give to the person.” Nurse
“I would say that it has made caregivers assertive. Nurses had interactions with caregivers and so caregivers come freely to ask questions. They (caregivers) call on nurses because they have had some relationship with them (nurses).” Health directorate
“The game is fun, and the questions are good, interactive and informative. The nurse was good at explaining the answers for me to understand. I have learned a lot”. Mother
These three quotations illustrate how the interactive approach led to a better relationship between nurses and caregivers. This made it possible for caregivers to approach their health care providers with other health concerns and seek advice on how to manage these. Hence, this intervention improved the relationship between health care providers and their clients to ensure better health care.
4.2 Ownership
As stakeholders were involved at different stages during the development of the intervention, all stakeholders expressed ownership in different ways. The directorate representative shared her view:
“...at any point in time, they (researchers) came to us, discussed it with us and received our input as to how we can get the community members to participate and we looked at what we have already. So, I believe we made an input to the development of the intervention, I believe that together we actually own it”. Health directorate representative
The representative from the health directorate shares how the directorate was involved throughout the co-creation and adaptation of the intervention. However, a nurse expressed it differently:
“So, through the workshop (training of community health nurses on materials and delivery approach) the whole thing started. If I could remember, they brought the things (brochures and the board game) and they taught us to use it. So, we made demonstrations during the workshop”. Nurse
“A lot has been taught over the six-month period and we have learned a lot during the period where we were engaged. We feel proud to be part of this programme. I have learned a lot. Now we are waiting for the competition. We will bring the prize home”. Mother
Thus, the nurse expresses that she was not involved in the development of the materials but rather in the delivery of the materials. The mother in this quotation expressed her satisfaction with being a part of the pilot phase, but the quotation actually shows that mothers’ motivation to ownership was an inter-community competition of the game play and they looked forward to claim the victory. This inter-community competition was organized for the caregivers after the pilot phase of the intervention. Thus, stakeholders shared the sense of ownership differently.
4.3 Sustainability
The strength concerning sustainability of this intervention concerns the usefulness to both users (nurses and caregivers); its weakness, however, lies in the unavailability of resources and administrative buy-in. The quotation below explains the issues of sustainability.
“Sustainability means once we own it, it becomes part of us, something we will practice. It has its own advantage for health providers, like something they have learned, and it becomes part of them.” Health directorate representative
“Any outreach that we go to especially with the brochures, we start with health education, so that one was a plus for us because we have flyers and other things which we can use to educate mothers”. Nurse
“Such an informative programme. How we wish every mother took this programme seriously. It is good to understand some basic health needs and this programme is a big help”. Mother
The above quotations show user buy-in and a high interest in the sustainability concerning use of the materials and the approach to information delivery. However, sustainability is challenged by the structure of health delivery services in Ghana where there is high attrition rate of health personnel at community level.
“What we are experiencing now is a high attrition rate. If a community health nurse goes into midwifery and is no more at the service area for child welfare, this means we lose, especially when the knowledge is not passed on”. Health directorate
“I used to go to the outreach facility but now I don’t go because I have taken over as an in-charge (higher position). The person who took over was in school and had just graduated so she has not started work yet. The one who filled in for her was also temporary, so I didn’t introduce it to her”. Nurse
“Sustainability is of concern, just as I said, if you go today and there is a different nurse and probably, they don’t know what is going on, they just do their thing and leave”. Research assistant
The quotations above show that the barriers to sustainability depend on the high attrition rate and regular reposting of health workers in the health district.
The representative from the health directorate suggested that in their routine review of health promotion activities in the district, they would include this interactive approach as one of the activities to be reviewed.
“So, during our reviews in fact, it’s an area we will review. And once it’s something that we are reviewing, it means it’s on our radar as one of the methods of service provision. Then we need to put in more effort to scale it up, otherwise, your guess is as good as mine”. Health directorate.
In summary, the sustainability strength of this intervention lies in its usefulness to users (nurses and caregivers) but its weakness lies in availability of resources and administrative buy-in.