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QUALITATIVE RESEARCH TO IMPROVE NEWBORN CARE PRACTICES
Ronald P. Parlato, Gary L. Darmstadt, and Anne Tinker
Saving Newborn Lives Initiative
© Save the Children 2004 All rights reserved. Publications of Saving Newborn Lives initiative of Save the Children can be obtained from Saving Newborn Lives, Save the Children US, 2000 M Street NW, Suite 500,Washington, DC 20036 (tel: 202-293-4170; fax: 202-637-9362). Requests for permission to reproduce or translate SNL publications for noncommercial distribution should be addressed to SNL Public Affairs Department at the above address. Save the Children does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed in the United States of America.
Editor: Robin Bell Editorial and design assistance: Julia Ruben Cover design: Kinetik Communications Front cover photo: Brian Moody Back cover photo:Thomas Kelly
SAVING NEWBORN LIVES INITIATIVE, supported by the Bill & Melinda Gates Foundation, is a global initiative to improve the health and survival of newborns in the developing world. Saving Newborn Lives works with governments, local communities and partner agencies in developing countries to make progress toward real and lasting change in newborn health. SAVE THE CHILDREN is a leading international nonprofit child-assistance organization working in over 40 countries worldwide, including the United States. Our mission is to make lasting positive change in the lives of children in need. Save the Children is a member of the international Save the Children Alliance, a worldwide network of 30 independent Save the Children organizations working in more than 100 countries to ensure the wellbeing and protect the rights of children everywhere.
SAVING NEWBORN LIVES TOOLS FOR NEWBORN HEALTH
QUALITATIVE RESEARCH TO IMPROVE NEWBORN CARE PRACTICES
Ronald P. Parlato, Gary L. Darmstadt, and Anne Tinker
Saving Newborn Lives Initiative Washington, DC
Many people put their thoughts, time, and effort into the shape and content of this publication. The authors wish to thank Nancy Nachbar and Annette Bongiovanni of the Academy for Educational Development, who made valuable contributions to early drafts of the document. La Rue Seims of Saving Newborn Lives, Save the Children, prepared parts of Chapter 4. Our thanks also go to Claudia Fishman of CDC, Peter Winch of Johns Hopkins University, Jose Martines of WHO, Nita Bhandari of AIIMS, Alessandra Bazzano of the London School of Hygiene, and Steven Wall, David Marsh, Frances Ganges, Malia Boggs, and Nabeela Ali of Save the Children, all of whom helped with their technical review. The authors are also grateful to David Oot, Director of the Office of Health, Save the Children, for his continued support and advice. Sarah Holland, Julia Ruben, Michael Foley, and Megan Renner deserve acknowledgment for for their assistance in the preparation of the document. Finally, the authors wish to thank all SNL staff who field-tested this guide and offered timely and useful comments throughout the development process. Without the generousity of the Bill & Melinda Gates Foundation, Saving Newborn Lives would not be able to adapt qualitative research tools to the urgent goal of reducing newborn deaths. Our thanks to the Gates Foundation for its support and guidance.
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii How to Use this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Chapter 1: Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Chapter 2: Intrapartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Chapter 3: Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Chapter 4: Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Chapter 5: Applying Data Analysis to BCC Planning and Programming . . . . . . . . . . . . . . . . . . . .33 Appendix: Qualitative Research Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 TABLES AND FIGURES Figure 1. Essential Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Table 1. All ENC Periods: Constraints and Lines of Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Table 2. Antenatal Period: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . . .13 Table 3. Antenatal Period: Constraints and Lines of Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Table 4. Intrapartum Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . .18 Table 5. Intrapartum Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Table 6. Immediate Newborn Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . .22 Table 7. Immediate Newborn Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . .24 Table 8. Neonatal Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . . . . .26 Table 9. Neonatal Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Table 10. Qualitative Research: Methods and Examples of Newborn Care Applications . . . . . . . .30 Table 11. Analyzing Qualitative Data and Developing a BCC Strategy . . . . . . . . . . . . . . . . . . . . . . .35
HOW TO USE THIS GUIDE
The purpose of this guide is to provide a ready reference tool for conducting qualitative research and planning a behavior change communications strategy to improve newborn care practices. In this guide, we label this research ‘qualitative,’ but it is important to note that the term ‘formative’ can be used to describe it as well. The guide has been designed with the understanding that the qualitative research and analysis could be carried out by subcontracted technical agencies or individuals who would supply the information to program managers. The program manager will not design, develop, or execute field studies, but rather will provide terms of reference and informed technical supervision and management. No matter how well-qualified, the researcher may be new to the subjects of Essential Newborn Care (ENC) and Behavior Change Communication (BCC). In this regard, this guide will help orient the program manager and the researcher to these technical areas and help to ensure that the research remains focused to generate information that will inform the design of BCC programs. This guide provides: supply factors shown in prior qualitative research studies to limit or discourage the adoption of evidence-based ENC practices. This guide also provides sample lines of inquiry that correspond to each current practice and constraint. These lines of inquiry are designed to suggest where and how to look for answers; however, they will need to be adapted for direct use in qualitative research questionnaires. • Guidelines for identifying target audiences and assessing the decision-making processes of their members. This can include assessing family decision-making. This can also include eliciting information about those members of the community, other than the extended family, who are influential in ENC decision-making—such as traditional practitioners and facility-based health workers. Not only is it important to identify who is exerting influence over important ENC decisions, but it is also imperative to understand the beliefs of those influential individuals themselves. • Procedures involved in qualitative research methods, such as in-depth interviews and focus group discussions.
• Evidence-based practices that have been shown to have the most significant and direct implications for newborn health, mortality • Practical guidance on how to move to the next steps after qualitative research—the all-imporand morbidity.1 These are the target practices tant phases of data analysis and BCC planfrom which to choose while designing the ning and programming. qualitative research. It is strongly recommended that only practices from this list be selected to ensure consistency and maintain a Introduction to Chapter Structure focus on evidence-based practices. Each of the ENC chapters (Chapters 1 – 3) of • Methods to identify the current practices of the guide includes matrices (Tables 1-9) presentlocal communities and lists of constraints— ing comprehensive lines of inquiry for both curinformational, social, cultural, economic, or rent practices and constraints.
How to Use this Guide 1
Each of these chapters is divided into the follow- Various factors might allow the researcher to ing sections: focus and simplify inquiries: 1. Presentation of evidence-based ENC practices and sub-practices and a discussion of their importance, answering the question: “What proven, evidence-based interventions lead to lower neonatal mortality and morbidity?” 2. Presentation of lines of inquiry to determine current ENC practices, answering the questions: “What are the current practices, and to what degree or under what circumstances might they be changed?” 3. Presentation of lines of inquiry to determine those constraints pertaining to each evidencebased practice, answering the question: “What factors inhibit or discourage people’s ability and willingness to practice evidencebased ENC?” These chapters address the three temporal periods of care: antenatal, intrapartum, and postnatal. Within each period there are major evidencebased practices and sub-practices, and for each of these there may be a variety of informational, social, cultural, economic, and supply constraints that limit or discourage behavior change. Nevertheless, it is unlikely that program managers will have to deal with all practices or all questions. • In some cases, a particular evidence-based practice is already common in the country. In Malawi, for example, antenatal care is already understood and practiced. Similarly, in many areas of Bangladesh, exclusive breastfeeding is the norm rather than the exception. Under these circumstances there is no need for additional research, for these practices will probably not require further attention. • Another consideration is whether other agencies are already addressing certain ENC practices. Another international organization, for example, may be implementing or have recently implemented a program to promote better maternal nutrition, exclusive breastfeeding, or tetanus toxoid immunization, thus obviating the need for additional research or programming. • In other cases, although no current or prior programs exist, there may be a sufficient body of existing knowledge on the subject. Others may have done exploratory research that is sufficient to form the basis for BCC planning in particular subject areas. In SNL focus countries, for instance, the baseline survey may supply enough relevant information to reduce the need for further investment in certain qualitative research topics.
2 Qualitative Research to Improve Newborn Care Practices
Newborn mortality is one of the world’s most neglected health problems. It is estimated that globally, four million newborns die before they reach one month of age and another four million are stillborn each year. Deaths during the neonatal period (the first 28 days of life) account for almost two-thirds of all deaths in the first year of life and 40 percent of deaths before the age of five. and delivery), and postnatal—and promotes a variety of interventions that have proven effective. The success of any program designed to promote and improve ENC practices depends on three key factors: 1. Increasing the demand for ENC practices
2. Providing relevant, appropriate, and useful Most of these deaths could be prevented information to enable individuals to act on through proven, cost-effective interventions, this demand such as tetanus toxoid immunization or exclusive breastfeeding. The Saving Newborn Lives (SNL) 3. Assuring the supply of those goods and servinitiative is designed to reduce neonatal mortality ices necessary to meet this demand and morbidity by strengthening and expanding these and other interventions in Africa, Asia, and For example, while clean delivery requires the Latin America. supply of a clean blade and tie to cut the umbilical cord, it first requires that families desire to use Behavior Change Communications (BCC) is these products. Thus, they need to appreciate the a process that provides timely, relevant, and benefits of a clean blade and tie and also know useful information to local communities how to use them. that can be used to encourage families to Figure 1: Essential Newborn Care improve newborn care practices. Successful IMMEDIATE NEWBORN CARE behavior change requires a thorough under• Drying and warming ANTENATAL CARE standing of the target audience. Qualitative • Ensuring breathing/newborn • Routine ANC visits resuscitation • Birth preparedness research provides essential information • Immediate breastfeeding • Danger signs/complications about what could motivate this audience to • Clean cord care improve its newborn care practices. This guide is intended to discuss behavior change within the context of Essential Newborn Care (ENC) and to provide guidelines on how to plan, manage, and use qualitative research and design a BCC strategy. Essential Newborn Care Practices As represented in Figure 1, the SNL initiative focuses on the three important periods of ENC—antenatal, intrapartum (during labor
Antenatal Care Intrapartum Care Postnatal Care
INTRAPARTUM CARE • Skilled attendance at delivery • Clean delivery • Danger signs/complications
NEONATAL CARE • Routine postnatal care visits • Exclusive breastfeeding • Maintenance of warmth/cleanliness • Newborn danger signs/complications
Adapted from: Marsh DR, Darmstadt GL, Moore J, Daly P, Oot D,Tinker A. "Advancing Newborn Health and Survival in Developing Countries: A Conceptual Framework." J. Perinatology 22 (2002): 572-576
Similarly, while birth preparedness requires identifying available transportation and upgraded referral facilities, it also requires a demand for these services as well as the ability to pay for them. On the informational side, families must first be able to recognize danger signs and complications, be confident that referral care will help ensure the survival of mother and newborn, and be motivated to act on this knowledge. Some practices, such as immediate and exclusive breastfeeding or drying and warming the newborn, require little in the way of supplies or products, but a great deal in the way of conviction. A new mother and her family must understand the value of immediate and exclusive breastfeeding, must value it enough to give up the traditional feeding habits for newborns and infants, and must be convinced that regardless of the practices of other women and their families, this practice will be beneficial for their child. Promoting evidence-based practices for newborn caregivers and modifying practices that are harmful will improve newborn health and reduce mortality and morbidity. However, for numerous reasons, demand for evidence-based newborn care practices is often quite low. First, many families do not receive the information required to understand the relationship between improved practices and better health outcomes. Second, the presentation of this information may not take into account existing social, cultural, and economic constraints to behavior change. Third, well-established and traditional newborn care practices may be strongly reinforced by family and community structures that tend to favor them over innovation. Economic constraints are perhaps the most significant of these barriers to demand for health services. Cost—whether a simple lack of funds or opportunity cost—is a formidable deterrent to behavior change.2
Social, cultural, and economic constraints are not insurmountable barriers to change. Understanding them can assist communications planners to customize the crafting of messages and media. In reality, improvements in newborn care practices have been seen throughout the world. Immediate and exclusive breastfeeding rates have increased dramatically in many countries due to successful BCC programs. Social mobilization campaigns have increased demand for tetanus toxoid coverage and thus reduced the incidence of death from a disease for which prevention is absolutely paramount. BCC initiatives have been equally successful in increasing rates of antenatal care and skilled care at birth. Qualitative Research Qualitative research offers specialized techniques for obtaining and understanding in-depth information about what people know, think, and do. Qualitative research analyzes social patterns and traditions that influence decision-making. It considers cultural beliefs and convictions that give a religious and philosophical significance to newborn care. It looks at economic constraints that limit the ability of families and communities to practice positive behaviors even when they may have the knowledge and conviction to do so. Qualitative research, however, is not merely descriptive; it is practical, useful, and dynamic. It investigates not only why people do what they do, but more importantly, what can help them to change. It provides the BCC planner with adequate information to identify the most effective entry point for behavior change negotiation, and the most acceptable and feasible degree of change within existing constraints. An example of how qualitative research data can be used to design appropriate and persuasive messages comes from the Hausa population in rural Nigeria. Qualitative research showed that immediately after birth, families commonly give
4 Qualitative Research to Improve Newborn Care Practices
newborns water that has been poured over paper on which verses from the Koran have been inscribed—a practice rooted in a centuries-old tradition. According to Hausa beliefs, this practice provides the vulnerable newborn the protection of Allah. At the same time, the Hausa believe that breast milk is good for the newborn and that through drinking breast milk, the newborn eats and drinks what the mother does. A BCC campaign promoting exclusive breastfeeding among the Hausa combined these two beliefs into a communication strategy. If the mother drinks Koranic verses, it was argued, the benefits would pass on to the newborn through her breast milk. Respecting both medical judgment (avoiding giving water to the newborn) and the local traditions and beliefs of the Hausa population, the campaign was a success. In this case and many others, qualitative research has provided BCC planners with the client-based data on which to ground the development of communication strategies—suggesting creative approaches to balancing demands of a traditional society with the value of modern health concepts. In short, qualitative research leads to an understanding of what people are currently doing, why they are doing it, what changes might be feasible within the context of existing constraints, and how communicators might effectively address these changes. At the same time, qualitative research can help the BCC planner rule out those ENC practices that might not be the most practical or viable priorities. Changing certain practices may simply represent too great a social, cultural, or economic risk to justify an investment of limited BCC resources. The practice of ritual prelacteal feeds, for example, is common in many parts of the world—often tied to long-standing cultural tradition, social practice, or religious belief.3 Although the Hausa were generally open to modifying their practice in favor of exclusive breastfeeding, other communities might consider discontinuing their
practice as a major breach in tradition. Prelacteal feeds often fulfill important sociocultural functions—uniting families, reaffirming family roles, sanctifying the life of the newborn, and demonstrating religious respect and homage. It may only be possible to modify the practice gradually, over the longer term. In general, the potential health impact of a behavior change should be assessed in relation to its feasibility and social acceptability—a judgment best made with the participation of the target community. Qualitative research, then, can provide answers to the following questions: • Which practices are likely to remain unchanged despite even the best BCC programs? • Which practices have the fewest social, economic, or cultural constraints and thus are most amenable to change and most likely to lead to improved health outcomes? • Which practices are amenable to change, but may not significantly impact health status and thus may not be valuable, cost-effective targets for BCC programs? • For practices that appear amenable to change and are known to have a significant impact on health, what might convince families to improve them? Constraints4 A constraint is defined as any factor that limits behavior change. Several types of constraints are detailed below: • Informational constraints refer to the client’s lack of information regarding current or recommended ENC practices and their health outcomes. That is, aside from social, cultural, and economic constraints, a major reason for not adopting a new pracIntroduction 5
tice can simply be lack of knowledge and a sound understanding of its availability, use, or benefits. • Social constraints refer to social patterns in a community that discourage the adoption of new ENC practices. For example, in many traditional areas, older relatives such as mothersin-law still have considerable say over decisions concerning pregnancy, birth, and child care. In more modern urban communities, their influence may be weaker, while the influence of the mass media may be stronger. Similarly, husbands in more traditional areas may dictate their wives’ activities, but this influence may diminish in some urban areas where women have greater independence or education.
• Cultural constraints refer to cultural patterns and beliefs in a community that discourage the adoption of new ENC practices. Numerous traditions regarding pregnancy and childbirth are related to religious practice and reaffirm the important roles and convictions of family members. While such practices can certainly be modified, BCC planners must appreciate their multifaceted sociocultural nature and realize how slow they may be to change.
For example, beliefs in the spiritual endowment of the placenta can divert attention from and influence immediate care for the newborn. These beliefs can become a life or death matter, particularly
Table 1. All ENC Periods: Constraints and Lines of Inquiry
Lines of Inquiry
Determine the degree to which pregnant women and their famlies: 1. Can recognize danger signs and complications 2. Realize the importance of seeking care and know where to seek it 3. Understand hygiene and the need for a clean delivery Determine the degree to which: 1. Existing patterns of family authority and responsibility affect the adoption of ENC practices 2.The adoption of ENC practices is contingent upon social approval and/or results in any negative social consequences Determine: 1. How concepts of privacy and modesty affect decisions to seek antenatal, intrapartum, or postnatal care 2. How fatalism, acceptance of God's will, or a sense of political or social powerlessness affects ENC and care-seeking 3. How beliefs concerning the spiritual nature of the placenta affect the immediate care of the newborn Determine the degree to which: 1. Cost is a factor in the choice of delivery attendant or place of delivery; or in decisions to seek antenatal, intrapartum, or postnatal care or referral care for complications 2. Cost is a factor in practicing clean delivery (i.e., purchase of products such as a clean delivery kit) 3. Opportunity costs affect antenatal, postnatal, or referral care-seeking or other ENC decisions (e.g., exclusive breastfeeding) Determine: 1.The extent to which ENC health services and products are available at public health facilities, on the private market, or in local communities 2. If the quality of these products and services is adequate to attract clients, or at least to not discourage them
6 Qualitative Research to Improve Newborn Care Practices
in the first critical moments after birth Progressive Behavior Change when the newborn’s risk of asphyxia and hypothermia are greatest. Perhaps the most important aspect of qualitative research is the concept of progressive change. • Concepts of ‘hot’ and ‘cold’ are often That is, given the constraints that make behavior related less to temperature than philochange difficult, to what degree and under what sophical systems. Similarly, attitudes circumstances might individuals change? toward hygiene and cleanliness are often more a function of environmental reality For example, a family may be severely limited than lack of understanding. The concept financially and living on the margin in terms of of hygiene in a community without run- economic productivity. If, as a result, the family ning water, sanitation, fly screens, dust is unable to spare the time or resources for a covers, etc., is quite different from that in pregnant woman to make the four prescribed communities with the resources to exerantenatal care visits, encouraging her to attend cise such protective measures. at least one or two visits may be a viable shortterm alternative. • Economic constraints refer to either unavailability of cash or credit to pay for ENC Qualitative researchers need to evaluate whether goods and services, or opportunity cost situ- the existing constraints are so severe that change ations wherein the adoption of a new ENC is not possible, or more commonly, whether practice reduces productivity in other areas. incremental, progressive change may be more feasible. The question repeated many times Lines of Inquiry throughout this guide—“To what degree and under what circumstances might current pracLines of inquiry are simply guidelines for the tices be changed?”—goes to the heart of this researcher—not questions to be inserted into a issue, and should be explored for each line of qualitative research questionnaire. They are inquiry presented in the various matrices. intended to suggest areas of investigation that previous research efforts have found productive. For example, if a pregnant woman states that For example, although there may be only one line after her last delivery she had not breastfed excluof inquiry in the matrix that concerns hygiene sively, the researcher would pose the question, and cleanliness (see Table 1), a field investigator “What would make it easier for you to adopt this would be expected to ask a number of questions practice?” before asking more probing questions, about the issue and would need to probe further: such as, “Do you think you could at least not give What is the current concept of cleanliness? How water to your newborn?” or “Would you considis it affected by environmental conditions? Is the er increasing the number of times you breastfeed concept of antisepsis understood? in a day?” In short, lines of inquiry should lead to deeper, core questions regarding ability and All lines of inquiry indicated in this guide are evi- willingness to change. dence-based. That is, research has shown they can elicit information about behavior, knowl- Behavioral trials, conducted with members of a edge, attitudes, and beliefs that are relevant to target audience in their own community, are parENC behavior change. Table 1 includes an amal- ticularly effective for assessing the feasibility of gam of many constraints and lines of inquiry for adopting new practices. As extensions of the all ENC periods. qualitative research process, behavioral trials
negotiate possible changes with families (previously identified through in-depth interviews, group discussions, focus groups, etc.) in a real life setting. This process can help validate the assumptions made from qualitative research and in the strategic planning process. In one study in Bangladesh, qualitative research determined that bathing the newborn on the first day of life was almost universal. This practice was based on the conviction that an infant is born unclean and therefore must be cleansed before being handled. This perceived “uncleanliness” has more to do with ritual, tradition, and ceremony than with practical, common desires to cleanse the newborn of blood and afterbirth. BCC planners wondered whether families might compromise between current practice and no bathing at all. In a series of behavioral trials using a doll to simulate possible practices, the planners identified a set of new practices that were closer to the ideal and acceptable to trial families. One of the most successful compromise practices was giving a brief sponge bath with warm water, in a warmed room, followed by immediate drying and wrapping with clean, dry cloths. Target Audiences In addition to addressing factors that determine behavior, qualitative research is also essential for identifying those individuals who exert the greatest influence on newborn care decisions because mothers rarely make these decisions on their own. Although mothers-in-law and husbands are often cited as the key influentials in ENC family decision-making, their influence varies according to local practice, and they are not the sole source of authority. For example, husbands often have the strongest influence on economic decisions regarding both financial outlay (e.g., funds for emergency transport, purchase of clean delivery equipment) and opportunity cost. A husband, who may be
required by social custom to accompany his wife on trips outside the family compound or community (e.g., to the health center for ANC), may be unwilling to give up what he considers to be more productive labor time. Traditional healers are another common influence. Though losing authority and respect in some communities as modern media and ideas make inroads, they remain powerful and influential in more isolated communities. Overall, an accurate identification of key influentials in a community is best made on the basis of qualitative research. Research Methods Qualitative research is usually conducted using standard methodological tools. The two most common are in-depth interviews and focus groups. These and other useful methodological tools for qualitative research are discussed in some detail in Chapter 4. Strategic Planning An understanding of the informational, social, cultural, and economic constraints that determine family and community behavior opens the door to communicating with target populations. Research data are valued most when they are used to guide the BCC planner in the development of BCC campaigns using electronic, print, and other mass media, and/or interpersonal communication. As mentioned above, qualitative research can enable the BCC planner to select priority practices—those leading to the greatest improvements in newborn health and survival and which are amenable to change. As evident in Figure 1 (page 3), several ENC practices are recommend-
8 Qualitative Research to Improve Newborn Care Practices
ed, and each one of these practices can be broken down into sub-practices. For example, interventions to promote breastfeeding include: a) encouraging a mother to put her newborn to the breast immediately, b) encouraging her to avoid prelacteal or interlacteal feeds, c) encouraging her to feed colostrum, d) helping her to appropriately position the infant at the breast, and e) encouraging her to continue feeding exclusively throughout the first six months of her infant’s life. Based on the data generated from clients, a BCC planner can make critical decisions concerning which of the major ENC practices and sub-practices should be considered the highest priorities. Qualitative research can also enable the BCC planner to determine the appropriate communication strategy for each selected priority practice. If drying and warming are selected as priority practices, how should one work with the community to promote these practices? To what beliefs, expectations, and hopes should one appeal? Some communities, such as those in the altiplano of Bolivia, already warm a room before
birth. That is, they understand the importance of receiving a newborn in a warm environment. A possible communication strategy to promote drying, wrapping, or skin-to-skin contact might begin with ambient temperature and the concept of warmth as they experience it as adults, and then advance to more thorough practices for their newborns. Qualitative research data can be used to identify specific target audiences: influential members of the family and community, newborn caregivers and health providers, and pregnant women themselves. Importantly, qualitative research can help program managers design information and media specifically tailored to these audiences, given their particular roles and responsibilities within the family and community. The strategies noted above are provided as examples to illustrate how qualitative research data can be transformed into a BCC strategy. These and other issues relating to the application of qualitative research data are explored in some depth in Chapter 5.
CHAPTER 1: ANTENATAL CARE
1.1 What proven, evidence-based issues such as nutrition, hygiene, family planinterventions lead to lower neona- ning, preparation for breastfeeding, child development, minor discomfort during pregnancy, tal mortality and morbidity?
1. Pregnant women should make at least four ANC visits to a health provider trained in midwifery skills. 2. Pregnant women and their families, as well as health providers, should be able to recognize danger signs and complications of pregnancy, and know when/how to seek appropriate referral care if needed. 3. Pregnant women, families, and communities should prepare for birth, including their responses to potential maternal and newborn emergencies.
and danger signs and complications, can also be an effective method for encouraging healthy household practices.
The World Health Organization (WHO) recommends at least four ANC visits. However, it is not only the number of ANC visits that is important; the quality of service and counseling received is even more important. As mentioned previously in the introduction, both demand and supply must be assured. Recognition of danger signs and complications of pregnancy: Regardless of whether a woman seeks ANC, it is important that she, her family, and her health providers know when, how, and where to seek care from an appropriately skilled professional. Below is a list of priority danger signs and complications during pregnancy of which everyone should be aware: • • • • • • Vaginal bleeding Convulsions (fits) Loss of consciousness Severe headaches with or without dizziness Fever Difficulty breathing (especially with dizziness and/or very pale skin) • Contractions/labor pains or water breaking before 37 weeks gestation If the mother experiences any of the above, she should know to seek professional care immediately, day or night, as these signs could indicate a life-threatening condition for her and/or the fetus.
Routine ANC visits: Antenatal care is important, not only for the clinical appraisal of pregnancy and remedial clinical interventions performed by trained professionals, but also for the counseling and educational services provided for the benefit of both mother and newborn. Ensuring proper tetanus toxoid immunization, educating women on the danger signs and complications of pregnancy, and preparing them for immediate, exclusive breastfeeding are particularly important. Although their significance varies geographically, maternal malnutrition, malaria, and reproductive tract infections may adversely affect newborn health outcomes;5 thus they should also be addressed in the context of ANC. Professional counseling by trained staff (and in some cases, trained peer counselors) regarding
Antenatal Care 11
The mother should also be aware of less seri- Qualitative research should first investigate pracous danger signs that require consultation as tices currently performed during pregnancy relasoon as possible: tive to the evidence-based practices listed above: Do women go for ANC? When and how fre• Pale skin quently? What is the content of these visits? Can • Cloudy urine they and their families recognize danger signs • Foul smelling vaginal discharge and complications during pregnancy? Do fami• Swelling of the face, hands, feet, or legs lies adequately prepare for birth and anticipate the possibility of an emergency? Birth preparedness: The third important antenatal practice for a pregnant woman, her family, Recognizing danger signs and complications can and her community is preparation for the birth be a problematic line of inquiry for the qualitaand any potential referral care needs. Birth pre- tive researcher, due to the subjective nature of paredness may affect newborn survival by ensur- many symptoms. For example, in communities ing that in the event of serious danger signs and where diarrhea, malaria, or upper respiratory complications, not only will they be recognized, infections are common and frequent, a fever may but the mother and newborn will be able to reach be overlooked or disregarded and its significance an appropriate medical facility in a timely fash- inaccurately gauged. Difficulty breathing is also ion, and the family will be able to access and subject to local interpretation, particularly in the afford quality emergency care. Thus, “preparing” preterm infant or in the presence of frequent for birth consists of several practices: respiratory infections or environmental pollution • Selecting a skilled birth attendant6 • Selecting a health facility to go to if the mother or newborn experience complications • Identifying and assuring emergency transportation to a health facility • Setting aside sufficient money to pay for emergency transportation and medical care and dust. Therefore, it is important not only to find out what people claim to know and recognize, but also to ascertain the depth and accuracy of their knowledge. Identifying and using the local terms for commonly recognized danger signs can also be essential for eliciting and recording accurate responses.
The second step for qualitative research should be to determine what it would take for families to adopt more positive behaviors—how and to what degree could the current practices be modified? Based on an understanding of the informational, social, cultural, economic, and supply conIdentifying current newborn care practices is the straints, good researchers may be able to infer first step in preparing a foundation for the design what changes are feasible. However, it is only by and development of a BCC program. Under- probing prospective behavior that one can deterstanding the degree to which women and their mine the real degree of change that might be families would be willing to accept new practices acceptable and achievable. and change their current behavior—that is, what changes they would make and under what condi- For example, if a woman states that she does not tions they would make them—is essential to craft- seek ANC because of economic constraints, she ing realistic, relevant behavior change messages. might reconsider attending just one antenatal
1.2 What are the current practices, and to what degree or under what circumstances might they be changed?
12 Qualitative Research to Improve Newborn Care Practices
visit instead of four. Similarly, another woman might be unwilling to seek ANC more than once because of cost, but she might agree if the visit could be made at home. She might also agree to pay for ANC visits if she perceived the quality of service to be better. Overall, although families may not be willing or able to take all recommended birth preparedness measures, they might be willing to take some of them. An understanding of the positive potential for progressive behavior change, in addition to an understanding of the negative constraints on behavior change, is essential to the crafting of effective BCC strategies and messages. Table 2 lists priority practices of the antenatal period and several corresponding lines of inquiry that researchers may want to address to determine the current level of compliance with evidence-based practices.
1.3 What factors limit or discourage people’s ability and willingness to practice evidence-based ENC?
There are four major categories of demand constraints that affect ability and willingness to move from existing newborn care practices to the evidence-based ENC practices recommended by SNL: • Informational constraints: a simple lack of information, knowledge, or experience needed to make informed ENC choices • Social constraints: patterns of family and community authority, roles, and responsibilities • Cultural constraints: religious beliefs or traditional rituals and other practices
Table 2. Antenatal Period: Lines of Inquiry about Current Practices
Lines of Inquiry
Determine: 1.Whether pregnant women currently receive any ANC 2. If they do, where and from whom they receive it 3.The timing and frequency of these visits 4.The procedures performed and counseling provided during these visits 5.What would facilitate an increased number of visits
Routine ANC Visits
Determine: 1.When respondents feel that mother or newborn are in danger during pregnancy, and the local terms for these symptoms of illness Recognition of Danger Signs and Complications of 2.What their responses would be to these symptoms 3.The health provider or facility to which they would go to seek care for these symptoms Pregnancy 4.Which danger signs/complications are generally perceived or recognized as such; and which ones are not recognized, misperceived, or misinterpreted Determine if pregnant women and their families: 1. Select a skilled birth attendant to assist at delivery 2. Prepare for emergencies that might occur during pregnancy, labor, or delivery 3. Identify a particular health facility to go to in case of an emergency 4. Identify emergency transportation 5. Set aside funds for emergency care and transportation 6.What would facilitate 2-5, above Determine: 1. If there is a community fund for use in maternal or newborn emergences 2. If so, how families gain access to this fund
Antenatal Care 13
that local terms are identified, the local context is understood, and the respondents answer as clearly as possible. Interviewers should determine only whether people’s knowledge conforms to the clinical definitions used by the researcher. Finally, it is Some of the issues meriting particular attention important to explore prospective responses to in the antenatal period include: symptoms; specifically, from whom and under what circumstances help is sought. ANC visits and economic constraints: Although the concept of financial cost will be Birth preparedness: While health professionals easily understandable to families and field inter- understand implicitly the need for emergency viewers, the concept of opportunity cost may not preparation, many local residents may not apprebe. In fact, it is likely to be far greater than any ciate its importance. This is due not only to inforcash outlay. Field investigators must be aware of mational constraints, but also to cultural percepthis factor and probe for relevance. Male family tions of risk, destiny, or fate, and economic permembers, for example, may not wish to accom- ceptions of power. That is, the cost of preparing pany their wives to the clinic simply because they for an emergency for middle class urban families do not feel they can lose a valuable morning or may be considered relatively small compared with day of work. the benefits. This is not likely to be true for poor rural families living on the economic margins. Knowledge and understanding of danger Similarly, middle class urban audiences may have signs and complications: Assessing family gained a certain confidence in public and private members’ knowledge on this topic is not a health facilities, believing that they can in fact straightforward task. It is complicated by the sub- improve health outcomes, while poorer families jectivity of many of the symptoms—including may believe that they are better off caring for the their context—and the various local terms used mother and newborn at home. In short, while the to describe them. Bleeding, for example, may be concept of birth preparedness seems simple and considered natural and normal during pregnancy, straightforward, current practices may be intias some spotting is quite common. Similarly, the mately linked to subtle informational, social, culexpression “difficulty breathing” may simply be tural, and economic factors. applied to a bad cold or congestion during a very dusty, windy time of year. Therefore, interview- Table 3 provides lines of inquiry that have proven ers must be trained to probe carefully to ensure fruitful in research on antenatal care practices.
• Economic constraints: deficiency of individual, family, or community resources, translating into lack of access to health goods and services
14 Qualitative Research to Improve Newborn Care Practices
Table 3. Antenatal Period: Lines of Inquiry about Constraints
Lines of Inquiry
Determine whether pregnant women and their families: 1. Know the benefits of seeking ANC 2. Understand the importance of attending ANC more than once 3. Understand the importance of proper home care during pregnancy 4. Understand the importance of preparing for a maternal or newborn emergency 5. Understand the relationship between danger signs and complications during pregnancy and maternal and neonatal mortality and morbidity 6. Understand the relationship between proper care during pregnancy and positive birth outcomes Determine: 1.The necessity of having an accompanying male relative 2. Privacy or modesty concerns about disrobing in the presence of a health provider 3. Other religious or cultural rituals or beliefs 4. Perceptions of service quality Determine if cost is a factor in: 1. Selection of health providers 2. ANC attendance 3. Setting aside of emergency funds for transportation and care Determine if the availability of transportation affects ANC attendance or emergency care planning Determine how other obligations (e.g., work, childcare) affect ANC attendance.
Social and Cultural Constraints
Transportation Constraints Time Constraints
Determine: 1.The most influential family or community members for each major antenatal practice Influence of Decision-Makers 2.Whether their influence is positive or negative (i.e., how or to what extent the influential party encourages or discourages evidence-based practices) 3.What influence pregnant women have, if any, over decisions concerning care during pregnancy
Antenatal Care 15
CHAPTER 2: INTRAPARTUM CARE
2.1 What proven, evidence-based Recognition of danger signs and complicainterventions lead to lower neona- tions of labor and delivery: As with antenatal care, the second aspect of intrapartum care tal mortality and morbidity?
1. A skilled birth attendant should assist at the delivery. 2. Pregnant women and their families, as well as birth attendants, should be able to recognize danger signs and complications of labor and delivery, and know when/how to manage or seek appropriate referral care if needed. 3. All deliveries should be “clean” to prevent infection.
critical to the survival and well-being of mother and newborn is the ability to recognize when to seek referral or emergency care from an appropriately trained professional. Below is a list of priority danger signs and complications of the intrapartum period of which everyone should be aware: • • • • • • • • Bleeding Convulsions (fits) Loss of consciousness Prolonged labor >12 hours Preterm labor Prolapsed cord or noncephalic presenting part Meconium discharge during labor Fever
Skilled attendance at delivery: The importance of this aspect of intrapartum care has been well documented historically. However, at present only about half of all women in developing countries deliver with a skilled attendant. When a skilled attendant is not yet available, trained community-based birth attendants can help improve newborn health and survival. Incorporating community-based health providers in maternal and neonatal health programs should be accompanied by strengthening the links along the household to the hospital continuum of care, including a long-term plan for training and providing sufficient skilled attendants. All SNL programs focus on strengthening the midwifery skills of birth attendants, whether at health facilities or in the community, to provide counseling, conduct clean and safe deliveries, recognize danger signs, take appropriate action to help both mother and newborn survive, and refer complicated cases to a higher level of care as needed.
Because a woman in labor may not be able to assess her own risk, it is important that the birth attendant immediately recognize and appropriately manage or arrange referral care for danger signs and complications. Therefore, qualitative research should be designed to assess the knowledge and understanding of mothers, their families, and birth attendants. The birth preparations recommended in the antenatal period (identifying a referral facility, securing emergency transport, and setting aside emergency funds) play their most critical role in the intrapartum period. These measures can expedite transfer of the mother and newborn in an emergency, thereby saving lives. Clean delivery: Newborns are also more likely to survive if the delivery is clean—that is, if
Intrapartum Care 17
actions are taken to help prevent infection. Just as 2.2 What are the current prac“preparing for birth” consists of several practices, tices, and to what degree or under ensuring a clean delivery also is comprised of a what circumstances might they be set of sub-practices. A “clean delivery” means:
• All those attending to the mother or newborn wash their hands with soap and water Again, the first step for qualitative research is to investigate the practices currently followed during before, during, and after delivery the intrapartum period in relation to the evidence• Perineal area is washed before each examina- based practices listed above. Second, the research tion and before delivery, and nothing foreign must determine the degree to which and under is put into the vagina (i.e., nothing but the what conditions behavior change would be acceptable and feasible. This helps to ensure the design of examiner’s hand, and only when necessary) a BCC program that is both realistic and relevant. • Delivery surface is clean or, at a minimum, the birth does not occur on the bare floor Thus, qualitative research should first obtain information about the practices and procedures or ground currently followed during labor and delivery: Who is present at what times during labor and delivery? What do they do to assist the birth? Can they recognize danger signs and complicaTable 4. Intrapartum Care: Lines of Inquiry about Current Practices
Lines of Inquiry
Determine: 1.Whether pregnant women use a skilled attendant for delivery 2.Where pregnant women deliver, whether at home or at a health facility 3.Who attends to the needs of mother and newborn during labor and delivery 4. If a family would consider using a skilled birth attendant for delivery, and what would make this decision easier and/or the practice more acceptable or feasible
Skilled Attendance at Delivery
Determine: 1.When respondents feel that mother or newborn are in danger during labor and delivery, and the local terms for these symptoms of illness Recognition of Danger Signs 2.What their responses would be to these symptoms and Complications of Labor 3.The health provider or facility to which they would go to seek care for these sympand Delivery toms 4.Which danger signs/complications are generally perceived or recognized as such; and which ones are not recognized, misperceived, or misinterpreted Determine: 1.Whether those attending to mother or newborn wash their hands with soap and water before, during, and after delivery 2. On what surface women deliver, whether it is cleansed with soap and water or other traditional materials, and whether it is cleansed more than once during labor and delivery 3.Whether the perineal area is cleansed before vaginal examinations and delivery 4.What would make these decisions about cleansing easier and the practices more acceptable or feasible 5.Whether anything foreign is put into the vagina, and under what conditions this practice might be discontinued
18 Qualitative Research to Improve Newborn Care Practices
tions during delivery, and what are their dition people’s ability and willingness to change responses to these? Are clean delivery proce- intrapartum care practices. When investigating these constraints, there are a number of impordures followed? tant issues that must be addressed for the intraWith regard to recognizing danger signs and partum period. Some which merit particular complications, it is again important to find out attention include: not only which symptoms are known and recognized, but also the depth and accuracy of this Birth attendants: While the advantages of knowledge and what actions they would prompt skilled birth attendants may be obvious to proin response. It is also important to understand fessionals, families, influenced by norms of tradihow birth attendants respond to danger signs or tion, trust, friendship, and privacy, often have a different perspective. They may also be suspicomplications during delivery. cious of letting “outsiders” into personal matAfter identifying current practices, qualitative ters, and may rightly conclude that a skilled birth research should then determine what it would attendant will cost more. Qualitative research, take for the adoption of evidence-based prac- therefore, must probe the depths of these contices. If a pregnant woman does not practice victions, and determine whether and under what clean delivery, what might make such changes conditions the use of birth attendants might more acceptable or feasible? Under the current become more acceptable or realistic. circumstances, what would be the most appropriate degree of change to promote? For example, Concepts of privacy and modesty: In socialthough families might consider it awkward or eties where these concepts are highly valued for cumbersome to have the birth attendant wash women, families may not choose birth attendants her hands during delivery, they might accept the who require that they undress (as may be more important practice of washing immediately required by many doctors and nurses) or may before. If they feel that physical cleaning of the avoid facilities where they would be in the presdelivery surface is all that is required (i.e., no spe- ence of strangers. cial birthing cloth or plastic) and are unwilling to change, they might consider the more important Knowledge and understanding of danger signs and complications: Determining knowluse of a clean blade and tie for cord care. edge of danger signs and complications is comTable 4 (page 20) lists priority practices of the plicated by the local terms and context, as well as intrapartum period and several corresponding by the subjectivity of many of the symptoms. lines of inquiry that researchers may want to Interviewers must probe carefully to ensure that address to determine the current level of compli- responses are clear and accurately interpreted; they must be trained to assess only whether ance with evidence-based practices. knowledge conforms to the clinical definitions of 2.3 What factors limit or discour- the symptoms.
age people’s ability and willingness Clean delivery: This is a complex subject to practice evidence-based ENC? because it is comprised of several sub-practices;
researchers will have to explore each one carefulAs with antenatal care, a variety of informational, ly. For example, hand washing before delivery may social, cultural, economic, and other factors con- seem logical and immediately understandable to
Intrapartum Care 19
skilled health providers, but may not be so to trained birth attendants and families who are often used to hand washing after delivery. Similarly, while there may be many families who would consider hand washing before delivery, they may find it awkward or inconvenient to wash frequently during delivery.
Perhaps most importantly, many families may not be aware or understand that using soap and copious amounts of water can help prevent infections. They also may not possess the financial resources to buy soap or may not have easy access to clean water, particularly if it must be carried from afar or has a high economic value.
Traditional concepts of cleanliness and Table 5 provides lines of inquiry that have hygiene: In many cases, local or traditional atti- proven fruitful in previous research on intratudes underlie decisions concerning clean deliv- partum care practices. ery; thus researchers should address these.
Table 5. Intrapartum Care: Lines of Inquiry about Constraints
Lines of Inquiry
Determine if pregnant women and their families: 1. Understand the importance/benefits of using trained/skilled birth attendants 2. Understand the relationship between danger signs and complications during labor and delivery and maternal and newborn mortality and morbidity 3. Understand the importance of washing hands with soap and water before, during, and after delivery 4. Know the benefits of delivering on a clean surface Determine: 1.What benefits or harm are perceived to result from putting foreign objects into the vagina 2. Families' perceptions about the availability of emergency care, and the quality and cost of that care 3.Why women say they do not give birth on a clean surface Determine: 1.The common perceptions of "clean" and "dirty" (e.g., of hands, of instruments used during delivery, or of the surface on which the woman gives birth) 2.The common definitions of a clean/dirty environment 3.The perceptions of a link between cleanliness and infections, if any 4.The degree to which poor facility attendance is influenced by perceived low quality of service and attention Determine to what degree the following inhibit choosing a birth attendant/institutional birth: 1.The necessity of having an accompanying male relative 2. Privacy/modesty - concerns about disrobing before a health provider 3. Other religious or social rituals or beliefs 4. Unacceptable/unfamiliar practices Determine: 1.The extent to which cost influences the choice of delivery attendant or place of delivery (home or facility) 2.Whether families feel that they have access to and can afford the supplies they need to ensure clean delivery (e.g., soap and water, cloths or towels)
Social and Cultural Constraints
Transportation Determine how, if at all, transportation issues affect the choice of delivery attendant or place, or careseeking for danger signs and complications. Constraints Influence of DecisionMakers Determine: 1.The most influential family or community members for each major practice listed above 2.Whether their influence is positive or negative (i.e., how and to what extent the influential party encourages or discourages evidence-based practices) 3.The extent to which pregnant women have influence, if any, over decisions concerning care during labor and delivery
20 Qualitative Research to Improve Newborn Care Practices
CHAPTER 3: POSTNATAL CARE
3.1 IMMEDIATE NEWBORN CARE
3.1.1 What proven, evidence-based interventions lead to lower neonatal mortality and morbidity?
1. Newborns should be thoroughly dried immediately after delivery and kept warm. 2. Newborns should be observed for crying and breathing immediately after delivery; asphyxiated newborns should be recognized and resuscitated. 3. Newborns should be immediately breastfed. 4. Cord care procedures should be clean.
There are two possible practices in this regard: • Lay the newborn on the mother’s abdomen, with the mother’s skin touching the newborn’s skin (skin-to-skin contact, also referred to as Kangaroo Mother Care). Cover both newborn and mother with a clean and dry cloth, towel, or blanket. • If skin-to-skin contact is not possible, lay the wrapped newborn on the mother’s abdomen or next to the mother on a clean and dry cloth, towel, or blanket. Cover the newborn and keep him or her covered with another clean and dry cloth, towel, or blanket. Bathing the newborn is generally not necessary on the first day, and should be postponed until the infant is stable—at least six hours, but preferably no earlier than 24 hours after birth. The bathwater and the room should be heated when bathing. Ensuring breathing: The newborn that, despite the stimulation provided by vigorous drying, has not cried, is not breathing regularly, or is gasping one minute after birth, needs immediate intervention. The skilled birth attendant should be equipped and prepared to perform resuscitation, preferably by bag-and-mask. Immediate breastfeeding: The newborn should be breastfed within one hour after birth, and should be fed only breast milk (see section 3.2). Clean cord care: Clean cord care practices are crucial to prevent infection. The umbilical cord should be cut with a clean (boiled) blade and tied with clean (boiled) materials. No substances should be put on the stump.
Drying and warming: A newborn regulates his or her body temperature much less efficiently than an adult, and loses heat more easily, especially from the head. To prevent hypothermia, the newborn should be thoroughly dried with a clean cloth or towel as soon as the head and body are fully delivered and before the placenta is delivered. Besides limiting loss of body heat, the stimulation this provides can promote breathing and aid an asphyxiated newborn. The newborn should then be wrapped, including the head, with a clean and dry cloth or towel. In addition to immediate wrapping, the newborn’s warmth should be ensured after delivery through contact with the mother, especially for infants with a low birth weight.
Postnatal Care 21
3.1.2 What are the current practices, and to what degree or under what circumstances might they be changed?
As in the first two chapters, the first task for qualitative research is to elicit information about what people currently do to care for the newborn immediately after delivery. Specifically, the sequence of immediate newborn care should be explored: What is done to dry and warm the newborn, and when is this done in relation to delivery of the placenta? When and how is breathing assessed and ensured? How is the cord cut and
cared for? When is the newborn first breastfed? Second, the researcher must determine what it would take for the adoption of evidence-based ENC practices. For instance, although keeping warm is a natural human instinct, the newborn’s high risk of hypothermia and the consequent need for special attention to his or her warmth may not be well understood. Probing questions should be asked to determine what steps families might take to give their newborns added thermal protection. Might they consider drying the newborn before delivery of the placenta, providing at least a light covering, and keeping the infant in contact with the mother or another caregiver?
Table 6. Immediate Newborn Care: Lines of Inquiry about Current Practices
Current Practices Lines of Inquiry
Determine: 1.Whether newborns are dried and wrapped immediately after birth, and before delivery of the placenta 2. If so, how and with what materials 3. If not, whether families would consider drying/wrapping the baby immediately after delivery, and what might facilitate this 4.Where the newborn is placed immediately after delivery; before and after delivery of the placenta and after drying, and for how long 5.Whether the newborn has skin-to-skin contact with the mother 6. If not, whether families would consider it possible to put the newborn immediately against mother's skin/body 7.What would make this practice (or modifications of it) more acceptable or feasible 8.Whether the newborn remains with the mother immediately after delivery, and if separated, how soon after birth and for how long 9. How soon after delivery the newborn is first bathed and by whom (e.g., family member, birth attendant, etc.) 10. If it would be acceptable to delay bathing until the second day of life, if not longer 11.The temperature of the bath water and the room during bathing
Drying and Warming
Ensuring Breathing 1.Whether and when attention is given to assessing the newborn's cry and breathing, and who makes this assessment 2.What signs of breathing are assessed 3.What is done for the non-breathing newborn, by whom, and for how long 4. If breathing is not assessed (and assisted, if necessary) immediately after birth, what might facilitate this
Clean Cord Care 1.What instruments/materials are used to cut and tie the cord 2.What measures, if any, are taken to clean these instruments (e.g., if they are boiled) 3.What might facilitate the use of clean instruments for cord care 4.What substances, if any, are applied to the cord stump and by whom 5.The frequency and duration of this treatment 6.Whether it would be acceptable to simply keep cord stump clean and dry, and apply nothing
22 Qualitative Research to Improve Newborn Care Practices
Table 6 lists priority practices of the immediate postnatal period and several corresponding lines of inquiry that researchers may want to pursue to determine the current level of compliance with evidence-based practices.
and of even greater urgency. Consequently, more attention is often paid to the delivery of the placenta than to the newborn. At the same time, because spiritual identity also means that the newborn and the placenta are equal beings at birth, mothers and caregivers should be able to 3.1.3 Which factors limit or dis- address the immediate needs of the newborn. In courage people’s ability and will- any case, this subtle and often profound belief ingness to practice evidence- has important ramifications for ENC behavior change and must be carefully explored.
Concepts of hygiene and cleanliness: Hygiene and aseptic conditions may be unknown or very difficult to achieve in many poor communities. People may be unaware of the environmental dangers of infection, and may be unable to do much to combat them. This pervasive Concept of warmth: While warmth appears to acceptance of unhygienic conditions may extend be a basic human concept, in reality there can be to cord care, newborn drying and wrapping, many subjective versions of warmth. Members materials, etc. of the same household often disagree on the most comfortable temperature. The elderly A related issue may arise in those cultures where often feel cold more intensely than the young. birth is considered polluting; in this situation, On the subject of ENC, many women who laying the newborn against the mother’s skin or experience a “shiver reflex” immediately after delaying bathing may be considered dangerous. birth draw the conclusion that their bodies and Moreover, these practices may be a violation of skin are colder than those of the newborn, and religious beliefs, perceived as compromising the thus refuse skin-to-skin contact. It is critical for religious standing of those who have contact investigators to gauge indigenous perceptions of with the “polluted” infant. There may also be warm and cold to create accurate and effective sociocultural reasons why families do not pracBCC messages of drying and warming. tice clean cord care; they may believe that applying certain substances on the cord helps it to Concept of the spiritual endowment of the heal, when in fact, this practice increases the placenta: While most Western cultures view the risk of infection. Often there is a religious or placenta as essential to the growth and survival cultural significance to the application of cerof the fetus while in the womb, but of no value tain substances. after birth, many other societies believe it is endowed with a spirit. Because of this separate Table 7 lists priority practices of the immediate spiritual identity, and also because of fears in postnatal period and several corresponding lines some societies that the undelivered placenta may of inquiry that researchers may follow to determove upwards in the chest and choke the mine the current level of compliance with eviwoman, the “delivery” of the placenta is often dence-based practices. considered as important as that of the newborn, When investigating constraints on immediate newborn care, there are a number of important issues that must be addressed. Those warranting particular attention include:
Postnatal Care 23
Table 7. Immediate Newborn Care: Lines of Inquiry about Constraints
Lines of Inquiry
Determine to what degree pregnant women, their families, and birth attendants: 1. Understand the importance of immediately drying and warming the newborn 2. Understand the importance of ensuring that the newborn is breathing, and if so, if they know how to stimulate breathing 3. Know the benefits of clean cord care, and understand the consequences of putting nothing/putting certain substances on the cord 4. Understand the effects of bathing the newborn immediately, and the benefits of delaying bathing 5. Understand the importance of warming the room and water for bathing Determine: 1.Whether the placenta is believed to be endowed with any spiritual nature and how this concept affects the relative way the newborn is regarded and the attention given him/her immediately after birth 2.Whether people think that what they do (e.g., to dry and warm the newborn, establish breathing, care for the cord in a clean manner, delay bathing) can have any impact on a newborn’s survival, and how 3.To what extent people feel that they can control whether their newborn lives or dies 4.Whether some people may consider it better for a newborn to die than to live, and if so why 5.Whether the belief that certain negative practices (e.g., not drying or attending to the newborn immediately after birth) are important to determine whether the infant is fit to survive 6.What effect religious beliefs, such as ritual pollution, have on immediate newborn care, particularly with regard to bathing Determine whether families can afford clean materials to dry and warm the newborn, to cut the cord, and to provide a warm bath (e.g., warm water, clean towels or cloths that have been washed in soap and water, a heating source for bath water, a heating source for the room). Determine the most influential members of the family and the community concerning the ENC practices discussed above. Determine: 1. People's definitions of "dirty and clean" (e.g., materials used for labor and delivery, hands/body parts, the instruments used during the delivery) 2.Whether people believe they can and should improve the hygiene and/or cleanliness of their household environment, and to what extent economic or environmental factors are constraints 3. If there are certain conditions that cannot be changed 4.When a cloth/instrument is considered "clean" and when a cloth/instrument is considered "dirty" 5. How, if at all, the occurrence of a maternal complication affects newborn drying and warming, establishment of breathing, cord cutting and care, and bathing practices
Social and Cultural Constraints
Economic Constraints Influence of Decision Makers
24 Qualitative Research to Improve Newborn Care Practices
3.2 NEONATAL CARE
In addition, it is very important that the infant is 3.2.1 Which proven, evidence- exclusively breastfed; that is, not given water or any other substances. Immediate and exclusive based interventions lead to lower breastfeeding are of particular importance for neonatal mortality and morbidity? preterm and low birth weight newborns. EVIDENCE-BASED PRACTICES
1. Mother and newborn should have routine postnatal care visits with a health provider, particularly during the first week after birth. 2. Newborns should be exclusively breastfed. 3. Warmth and clean environment should be maintained. 4. Mothers and their families should be able to recognize newborn danger signs and complications, and know when/how to manage or seek appropriate referral care if needed.
Maintenance of warmth and clean environment: The principles of keeping the newborn warm and maintaining cleanliness (particularly hand-washing when handling the newborn), remain priorities for preventing hypothermia and infection in the postnatal period. Special attention should be given to warming and hygiene for preterm and low birth weight newborns. Recognition of newborn danger signs and complications: As in the antenatal and intrapartum periods, the practice of complication preparedness is critical. The mother and her family, as well as health providers, should be aware of the following common danger signs and complications during the neonatal period: • Inability to feed adequately or cessation of sucking • Weak or abnormal cry or cessation of crying • Lethargy or loss of consciousness • Redness of the umbilicus extending to the skin of the abdomen • Discharge (pus) from the umbilicus • Localized skin infection (pustules) • Discharge from or redness of the eyes • Persistent vomiting and/or abdominal distention • Difficulty breathing (including chest in-drawing on inspiration or grunting on exhalation) • Fast breathing (> 60 breaths per minute) • Fever or unusually cold body temperature • Convulsions, seizures, or fits • Yellow discoloration (jaundice) of the skin— the further “down” the body (i.e., hands and feet) the worse the jaundice
Routine postnatal care visits: While the optimal timings of postnatal visits for healthy newborns have not yet been adequately tested in developing countries to allow an evidence-based recommendation, research suggests that key intervention times to prevent neonatal deaths are: immediately after delivery, on day 2 – 3, and on day 6 – 7, at a minimum. Exclusive breastfeeding: In the postnatal period, the most important practice is to establish immediate and exclusive breastfeeding. This benefits both the mother and the newborn. For the mother, immediate breastfeeding stimulates uterine contractions and delivery of the placenta, and thus may reduce the risk of postpartum hemorrhage. For the newborn, early breastfeeding provides nutrition and warmth, and colostrum (mother’s “first milk”) contains substances that help prevent infection.
Postnatal Care 25
3.2.2 What are the current prac- mothers and their families recognize newborn dantices, and to what degree or under ger signs and complications? Do mothers and what circumstances might they be newborns attend postnatal care visits? changed?
Qualitative researchers should first obtain information about current ENC behaviors for the neonatal period: When is the newborn put to the breast for the first time? Does the newborn receive anything other than breast milk in the first month (and throughout the first six months) of life? Are warmth and clean care practices maintained? Can
Just as it is important to identify current practices, it is also important to determine what it would take for evidence-based practices to be adopted. To what degree might progressive behavior change be possible? For example, exclusive breastfeeding is the exception rather than the norm in many countries. One reason, particularly in hot climates, lies in the perception that
Table 8. Neonatal Care: Lines of Inquiry about Current Practices
Lines of Inquiry
Determine: 1. How soon after delivery the newborn is put to the breast for the first time 2.What might facilitate breastfeeding immediately after birth, or make this decision easier or more acceptable 3.Whether mothers give colostrum to the newborn 4. If not, under what circumstances would mothers give colostrum 5.What substances (other than breast milk) are given to the newborn, who administers these, Immediate and and when and how frequently they are administered Exclusive Breastfeeding 6.Whether mothers would consider feeding nothing but breast milk/colostrum to their newborns 7. If not, whether mothers would at least be willing to reduce the amount/frequency of these prelacteal or interlacteal feeds 8.What would make the decision to exclusively breastfeed easier or the practice more acceptable Determine: 1. How the newborn's warmth is maintained during the neonatal period (e.g., contact with mother, wrapping, covering, etc.) 2.The frequency of bathing, and water/room temperature during baths 3.Whether those caring for the newborn wash their hands, with what, and how often 4. If other materials with which the newborn comes into contact are cleansed, and how/with what they are cleansed 5. If warmth and clean environment are not maintained, what would facilitate these practices or make them more acceptable
Maintenance of Warmth and Clean Environment
Determine: 1.When respondents feel that a newborn is in danger during the neonatal period, and the local terms for these symptoms Recognition of Newborn Danger Signs 2.What their responses would be to these symptoms 3.The health provider or facility to which they would go to seek care for these symptoms and Complications 4.Which danger signs/complications are generally perceived or recognized as such; which ones are not recognized or are misinterpreted Determine: 1.Whether newborns currently receive any postnatal care 2. If they do, where and from whom they receive it 3.The timing and frequency of these visits 4.The procedures performed and counseling provided during these visits 5.What would facilitate an increased number of visits
Postnatal Care Visits
26 Qualitative Research to Improve Newborn Care Practices
breastfeeding does not provide adequate fluid. However, a number of breastfeeding promotion projects have been successful in encouraging mothers to discontinue the practice of giving water to newborns, at least during cooler times of the year. Qualitative research should also explore possibilities for behavior change negotiation on the issue of prelacteal feeding. Prelacteal feeds, such as honey, tea, ghutti, or sugar water, can be harmful, as they may cause infections and diarrhea. The risks of this ritual are even more serious if substances (like honey) are routinely given a number of times as an interlacteal feed. The goal of qualitative research in these situations is to determine if there are conditions under which a family might agree to reduce the amount and frequency of prelacteal feeds. Limiting the practice to the anointing of the newborn’s lips, rather than actually introducing the food itself, might also be a feasible compromise in some cultures. Table 8 lists priority practices of the neonatal period and several corresponding lines of inquiry that researchers may want to address to determine the current level of compliance with evidence-based practices.
tional and immunological properties that it possesses. In many cultures, colostrum is considered an unclean substance that must be extruded (discarded) before the milk can be fed. Others consider it a purgative, and still others believe it to be a neutral, but non-nutritive cleansing substance. It is important for the researcher to determine the convictions that families have regarding colostrum’s negative properties, as well as the depth of these beliefs. In other words, in societies that believe colostrum to be simply a neutral, nonnutritive substance, changing practices may be much easier than in those societies that think it is a purgative. In areas where immunization programs are already well accepted, likening colostrum to the infant’s first immunization may be an effective behavior change message. Prelacteal feeds: Prelacteal feeds are considered an important social and cultural custom that, like marriage, confirmation, and circumcision, confer special importance on certain family members and confirm their role and responsibilities within the family. In some cultures, prelacteal feeds are religiously significant, the practice seen as bestowing God’s protection upon the newborn. While it is is, consequently, particularly difficult to eliminate, it may be possible to modify the practice, retaining its traditional ritual values while reducing the adverse health risks (see for instance, the Hausa ritual, described on p. 4-5). Breastfeeding and economic factors/opportunity costs: One of the greatest obstacles to exclusive breastfeeding can be the opportunity cost of the practice. While some BCC programs have portrayed breastfeeding as a no-cost option, in reality that is far from the case. Breastfeeding a newborn 8 to 10 times a day, which is usual in on-demand feeding cycles, represents a distinct economic cost whether a woman works within or outside the home. In modernizing urban societies where women work in the organized sector, exclusive breastfeeding may represent an opportunity cost that is simply too great to bear.
Postnatal Care 27
3.2.3 What factors limit or discourage people’s ability and willingness to practice evidence-based ENC?
For neonatal care, as with the previous ENC periods, a variety of informational, social, cultural, economic, and other factors can affect people’s ability and willingness to change to evidence-based practices. When investigating these constraints on neonatal care, there are a number of important issues that must be addressed. Those meriting particular attention include: Colostrum: Many societies reject feeding the newborn a mother’s colostrum, despite the nutri-
Similarly, in more traditional societies where women’s domestic labor is arduous and continuous, time taken for breastfeeding reduces other productive work. Therefore, the decision not to breastfeed is a logical one when the perceived economic benefits of labor exceed the perceived advantages of breastfeeding. Qualitative researchers should investigate the economic ramifications of breastfeeding and determine whether economically productive women could increase the frequency of breastfeeds.
born danger signs and complications listed previously may appear obvious to the experienced health professional, they are, in fact, somewhat subjective and open to local interpretation. It is critical that when performing qualitative research, interviewers define local terms and context for various illnesses and signs of illness, and agree upon minimum criteria to accept as recognition of each danger sign.
Table 9 suggests areas of investigation that have been productive in former research on neonatal Knowledge and understanding of danger care practices. signs and complications: Although the new-
Table 9. Neonatal Care: Lines of Inquiry about Constraints
Lines of Inquiry
Determine the perceived positive or negative effects of: 1. Giving colostrum to the newborn 2. Giving only breast milk 3. Putting the newborn to breast within an hour of delivery Determine whether mothers believes: 4.Their breast milk provides sufficient food and liquid 5.Their breast milk supply is adequate in the first month Determine: 1. Common perceptions of colostrum: whether it is considered dirty, a purgative, a non-nutritive precursor to breast milk, etc. 2.Whether there are any rituals in which substances are given to the newborn, and for what reasons 3.Whether keeping the newborn with the mother is perceived as important, and if not, why 4. How belief in the spiritual endowment of the placenta affects the timing of first breastfeeding (i.e., do women wait for the placenta to be delivered) 5.Whether families realize that breastfeeding helps stimulate delivery of the placenta and limit the risk of postpartum hemorrhage 6.Whether the mother’s age or the newborn’s birth order or sex is a factor in breastfeeding Determine: 1.Whether women's economic opportunities, at home or outside the home, interfere with exclusive breastfeeding 2.Whether women believe that their diet or inadequate food availability influence the quantity/quality of breast milk Determine whether mothers perceive exclusive breastfeeding in the first month to be more or less time consuming than other feeding alternatives, and what effect, if any, this may have on feeding behavior
Social and Cultural Constraints
28 Qualitative Research to Improve Newborn Care Practices
CHAPTER 4: RESEARCH METHODS
In a group interview, all respondents are interviewed and urged to respond. No attempt is The previous chapters of this guide provide lines made to record the answers for each respondent of inquiry to investigate current ENC practices separately. A group interview can be done using and the various constraints limiting ENC behavior a structured or semi-structured questionnaire change. Actual field research may be designed and with closed or open-ended questions. implemented on the basis of these lines of inquiry. Individual interviews may be more effective for There are many different qualitative research exploring sensitive topics that the interviewee methods available, ranging from those that are would not feel comfortable discussing in a group widely applicable, such as focus groups, to more setting, such as the relative value of a female child. specific, but equally useful techniques, such as mapping. The choice of methods depends on Table 10 presents these and other common qualmany factors. The two most commonly used itative research methods and gives the salient features of each, with examples of newborn qualitative research methods follow: care applications. Focus groups are best used to probe a complex, narrowly focused issue. A topic that For those program managers who desire more involves cultural and religious beliefs and prac- detailed and technical information about these tices, for example, may require the patient, delib- and other qualitative research methods, a list of erate, participatory techniques that characterize resources has been provided in Appendix 1. focus groups. A topic such as exclusive breast- Included are in-depth guides to both focus feeding, which is conditioned by a number of groups and group interviews and a general guide social, cultural, and economic factors, also lends to qualitative methods, with detailed instructions on their use. itself to focus group discussions. Focus groups are usually comprised of 8 to 12 4.2 Selection of Respondents, Data persons of similar background. A skilled facilita- Analysis, and Reporting tor guides the discussion—probing beliefs and attitudes underlying the topic of interest—while Selection of Respondents members of a study team may record answers. Techniques for the selection of respondents for Individual or group interviews are often used qualitative studies are not random, but rather when factual information needs to be collected, based upon the researchers’ judgment of which such as the current practices of health personnel. respondents would generate the best-quality data. It may be more efficient to collect this informa- In some cases, respondents may be selected who tion from a number of workers gathered in one are especially vocal, for example. Respondents are place than to interview them individually. A usually selected based on similarities in terms of group of health workers may be asked, for exam- criteria such as age, sex, and socioeconomic status. ple, “Why did you want to become a community health worker?”
Research Methods 29
Table 10. Qualitative Research: Methods and Examples of Newborn Care Applications Method Description Features • Generates detailed information regarding practices and constraints • Elicits information on sensitive topics Examples of Newborn Care Applications • Home care practices during pregnancy • Steps taken to prepare for delivery
• Uses a structured questionnaire with Individual open-ended quesIn-depth Interview tions to probe practices and beliefs in detail
• Uses a structured or • Allows for efficiently semi-structured collecting information instrument to probe from several responpractices and beliefs, dents at the same but anyone in the time group can respond
• The degree to which pregnant women and their families recognize danger signs and complications of the antenatal, intrapartum, and postnatal periods • The degree to which cost is a factor in the choice of delivery attendant or place of delivery
Focus Group Discussion (FGD)
• Explores central • Allows for in-depth • Practices surrounding initiation of themes or issues; exploration of focused breastfeeding allows for free and topics open discussion with debate • A trained observer is • The most accurate • Sanitation in the home, including present to observe way of recording pracavailability and use of soap and practices firsthand tices, but requires water highly skilled • Where the newborn is placed observers and is time directly after birth consuming • How the newborn is dried and wrapped • Uses actual or recre- • Enables participants to • Quality of care received during ated stories about a focus on a real-life antenatal, intrapartum, and postnatal particular topic to ENC situation periods explore practices • Often situates partici- • Process of birth and emergency and beliefs or pants within a familiar preparation prompt discussion sociocultural context • The first two types • Encourages partici• Community mapping of a village of mapping ask parpants to identify and with health post, health providers, ticipants to visualize describe systems or and TBAs to explore sources of community or social patterns with which help for newborn problems systems; body mapthey are so familiar • Social mapping of organizations, ping asks particithat they rarely define such as occupational, social, or relipants, for example, them gious groups to visualize their • Body mapping of reproductive reproductive systems organs, fetal growth, or bodily changes of pregnancy • Asks participants to organize and rank various elements of the ENC system • Indicates how respon- • Newborn or maternal danger signs dents prioritize items and complications grouped by type, according to particular severity, cause, frequency of occurcharacteristic(s) rence, and/or treatment
Narratives or Scenarios
Mapping Techniques • Community • Social • Body
30 Qualitative Research to Improve Newborn Care Practices
Data Analysis Qualitative data are most often analyzed by hand. The basic data analysis steps include reviewing, coding, summarizing, and interpreting the data collected. Community members may actively participate in the analysis either individually, in small groups, or in a workshop setting. Examples of how analyses for focus groups or interviews can be conducted include: • Individually or in small groups: Researchers go through their interview notes and for each respondent (e.g., mother), put the answer to each question on a separate index card. Then the index cards are reviewed, common themes are identified, and the cards are sorted according to each theme. Each theme can then be summarized in a few words and the results interpreted. • In a workshop: All researchers go through their interview notes together in a workshop. One question at a time is written on a flipchart, and interviewers read out all the responses they obtained for each question, while someone records them. The group next identifies the most common responses. Then, group discussion can focus on interpreting these common responses and deciding upon the appropriate actions to improve health interventions.
Chapter 5 explains how to set up an analytical framework for qualitative research. Reporting Qualitative research methods answer questions such as “who,” “what,” “when,” “where,” “why,” and “how.” Questions such as “how often” and “how many” are more appropriately answered by quantitative research methods. Reports of qualitative research, therefore, should state trends but should not attempt to quantify results using numbers or percentages. Examples of the types of statements that could be made on the basis of qualitative methods follow: • There was a general perception in the communities where group interviews were conducted that health care staff had improved their treatment of newborns and their mothers since ENC training was introduced. • Of those young mothers (< 20) who participated in focus groups in peri-urban communities, most mentioned the importance of antenatal care in improving safe delivery after community health workers began making house-to-house visits. Very few mentioned the importance of antenatal care in focus groups held before this intervention.
Including direct quotations from participants There are several computer programs that per- within the report can sometimes capture the richform analyses of qualitative data, and reader- ness of the data collected. friendly guides are available to aid in their usage.7
Research Methods 31
CHAPTER 5: APPLYING DATA A N A LYS I S TO B C C P L A N N I N G A N D P RO G R A M M I N G
Once qualitative research has been completed, the program manager will 1) analyze the information and 2) based upon this data analysis, make appropriate decisions concerning program design. BCC strategic planning will address both media programming—selection of outlets, design of messages, format, and presentation— and interpersonal communication (IPC) training and implementation programs. Certain practices are conditioned by economic necessity. For example, additional ANC visits represent opportunity costs, and the purchase of clean delivery kits or products may be inhibited by limited financial resources. Other practices are limited by access to or supply of goods and services. If emergency referral services are not available in a particular area, then it is programmatically unsound and ethically dubious to promote the immediate evacuation of mothers and newborns in distress to a health facility. Similarly, if emergency funds for birth preparedness are promoted but no community loan or transport systems have been created, the message may be quickly discredited. Therefore, program managers and researchers must recognize these limitations and identify sound priority practices. As has been shown in the tables throughout this document, lines of inquiry have been designed to answer the questions “Would you consider adopting X behavior?” and “To what degree or under what circumstances would you change your current practice?” Other lines of inquiry assess the nature and quality of existing practices; how deeply rooted, integral to social and cultural patterns, and strictly governed by existing networks of authority they are. An analysis of these lines of inquiry will answer: • When given sound ENC information from a trustworthy source, are people at all willing to change? • What are the easiest or first things they would change about their current practice?
5.1 Using Qualitative Research Data
The design of BCC programs will use the results of qualitative research in the following principle ways: 1. Identification of priority practices: If qualitative research has been conducted properly, considerable effort will have been invested in determining which current practices are amenable to change given informational, social, cultural, economic, and supply constraints. Qualitative research can also be used to offer insights into how and why current positive ENC behaviors are practiced or have come about. If certain practices, such as prelacteal feeds, are strongly embedded within traditional social patterns and cultural and religious beliefs, changing them may not be feasible— at least within the lifetime of most BCC programs. On the other hand, practices for which there are few prevailing sociocultural constraints may be relatively easy to change. For example, mothers who already understand the importance of ANC visits may quite readily agree to increase attendance from two visits to three.
After the Research 33
• Even if people indicate a willingness to change, is the change feasible within existing social, cultural, economic, and supply realities? It should be noted that the final selection of priority practices will be a function of two other important factors: • Epidemiology and tipping points: A particular practice may be considered feasible, given an analysis of constraints, but may not be cost-effective as a priority. For example, many countries have already achieved considerable success in increasing the rates of ANC attendance. Given the evolution of social norms, practices that have achieved 50% coverage tend to accelerate geometrically in acceptance past this “tipping point.” Thus, it will be far easier to achieve change from 50% to 60% than from 10% to 20%. Usually, as a practice becomes increasingly common and close to evolving into a social norm, social dynamics are such that little additional investment is required to move the population to near-complete compliance. • Parallel programs and investments: Most Safe Motherhood projects focus on ANC, recognition of danger signs and complications during pregnancy, skilled attendance at birth, and responsible and prompt referral. Therefore, although the qualitative research may show that these areas are particularly promising as priorities, other programs may already be adequately addressing them. BCC investments within the context of an ENC program, therefore, may focus on other priorities, such as postnatal care. 2. Selection of a progressive change strategy: The research results will provide the BCC programmer with valuable information con-
cerning possible strategies for progressive change—that is, the most acceptable and feasible degree of behavior change to promote for a particular audience at a particular time. Women in a recent BCC breastfeeding program in India were encouraged, as a first step to exclusive breastfeeding, to eliminate “top milk” (a water-based liquid thought to supplement or “top off ” breast milk). In many other countries, a similar focus in exclusive breastfeeding campaigns was placed on eliminating water from the newborn’s breastfeeding regimen. Because giving the newborn water has no particular religious or traditional significance, and because it is has such a pernicious effect on newborn health, this was an ideal place to begin the progressive behavior change process. Qualitative research inquiries will also point the researcher towards possible areas for negotiated behavior change. For example, some potentially harmful practices, such as bathing the newborn immediately after birth, may be modified or replaced by more positive practices, such as delaying bathing or cleaning the newborn instead with a warm, damp cloth. 3. Identification of behavioral entry points: Qualitative research data will provide valuable insights regarding entry points for behavior change—that is, common practices or beliefs on which one can build a case for improved ENC. For example, in many cultures there is a common practice of heating a room before the delivery of a child. Certainly, if there is already this belief about warmth, it could be built upon to encourage families to increase that warmth and also apply it in new circumstances. Similarly, if there is a strong cultural belief about the equivalent souls of newborn and placenta, this belief could be developed to stress the importance of caring for both simultaneously.
34 Qualitative Research to Improve Newborn Care Practices
All people are aware to some degree of the signs and symptoms of disease. A sore throat, runny nose, and sneezing may presage the onset of a cold. A queasy stomach often precedes diarrhea. BCC strategies should also be able to build on these common perceptions to increase the recognition and appreciation of danger signs and complications during the antenatal, intrapartum, and postnatal periods.
actually do—prelacteal feeds, early administration of water, supplemental feeding, etc. • Informational, social, cultural, and economic constraints: List those constraints that have emerged from the research and are most likely to interfere with behavior change. That is, what factors limit or discourage the practice of evidence-based ENC? • Supply constraints: The strategic planning process must also consider elements of ENC—such as service delivery, essential drugs, clean delivery supplies, etc.—from the perspective of supply. That is, although qualitative research will have identified families’ perceptions of the supply of these elements, the actual situation in terms of the availability of supplies and services must also be assessed. No responsible BCC program can promote the increased use of health facilities, their services, and supplies unless they are in fact already available and accessible or the ENC program has assured their availability. • Feasibility of change: Based on the information on constraints and underlying ENC practices, determine which of the current practices are the most likely to be modified. That is, for which of the high-impact practices are there a minimum of social, cultural, economic, and supply constraints? Rank the feasibility of change for each as high, medium, or low. • Behavioral trials of improved practices: Once high feasibility, high impact practices have been identified, additional exploration may be necessary to determine what women,
5.2 Setting Up an Analytical Framework
It is extremely important for program managers and researchers to develop an analytical framework for the qualitative research before the research begins. That is, the purpose and applications of the data generated and the manner in which it will be organized should be determined ahead of time. Table 11 is a suggested matrix for organizing the data gathered in qualitative research, which should be completed following the data collection: • Evidence-based practices: Before beginning qualitative research, select those practices that have the greatest potential impact on newborn health. Consider the relative anticipated health impact of the practices based on available evidence and rank the impact of each as high, medium, or low. • Current practices: After qualitative research has been completed, list the current practices of women, family members, or caregivers that correspond to each of the potential high-impact practices. For exclusive breastfeeding, for example, indicate what women
Informational, Social, Cultural, Economic, and Supply Constraints
Table 11. Proposed Matrix for Analyzing Qualitative Data and Developing a BCC Strategy EvidenceBased Practices Current Practices Feasibility of Change Behavioral Trials of Improved Practices Final Priority Practices Communication Strategies
After the Research 35
families, birth attendants, and communities would be willing to do to change them. Trials of improved practices can be a useful way to do this. They provide feedback on the probability of getting people to adopt a particular new behavior. These trials are a technique to elicit and negotiate those solutions that are the most appropriate, acceptable, and realistic from the client’s perspective. • Final priority practices: Given the effort required to change behavior, particularly practices rooted in ritual or tradition, it is important to select no more than 4 to 5 priority practices on which to focus in any BCC campaign or program. These priority practices should be taken from among those identified as both high impact and high feasibility. • Communication strategies: Finally, based on the behavioral information derived from qualitative research, determine the best communication methods for encouraging clients to change from current practices to priority practices. Qualitative research should answer the questions: “What information do clients need to help them move along the path to priority practices?” and “What might be the most persuasive and effective ways to present this information?” Communication strategies may also be derived from learning why and how families that have adopted positive ENC practices came to make these decisions.8
BCC Strategic Planning The BCC Strategic Plan is the formal document to be used by executing agencies, be they NGOs, research institutions, or governments, when selecting, designing, and developing media and materials, and when designing and implementing IPC training. It summarizes the results of the qualitative research and defines: a) the priority practices considered the most amenable to change and most likely to have the greatest impact on neonatal health and survival, and b) the communication strategies most appropriate for each priority practice. In other words, the plan identifies the most acceptable and effective ways to encourage people to progress toward adoption of evidence-based ENC priority practices. A communication strategy is derived both from responses to the question “What change might you consider in your current behavior?” and from an analysis of those factors that contribute to existing positive behavior. The BCC Strategic Plan is based on qualitative research data that have been subjected to a rigorous analytical process. Therefore, the plan offers conclusions and recommendations that have been derived directly from real-life experience. The priority practices presented in the plan are those meeting the criteria of high impact and high feasibility. The communication strategies presented should have been selected from many options, and should be those most likely to appeal to client communities. The BCC Strategic Plan, therefore, can be used as a guide for:
5.3 BCC Planning and Programming
The planning and programming steps to be taken after completion of data analysis are explained 1. Developing media below. In addition to the planning of the BCC program, a monitoring and evaluation strategy 2. Developing IPC training materials should be developed for performance assessThe plan will assist the program manager to ment and impact evaluation. develop media and IPC training materials in the following ways:
36 Qualitative Research to Improve Newborn Care Practices
• It will indicate which priority practices should be addressed. Given constraints of time and budget, the chances of behavior change increase when investments of time, effort and resources are focused on a few, key practices. • It will suggest the behavioral approach most likely to succeed for each priority practice within the particular social, cultural, and economic context. For example, in some countries an initial focus on immediate breastfeeding may be more likely to yield significant results than a focus on exclusive breastfeeding. Similarly, a program emphasizing that immediate breastfeeding eases placental delivery may be more effective in bringing about behavior change than the more common nutritional or immunological arguments. Media Selection, Design and Production The following are suggested guidelines for creating effective media: • The selection of media should be based on coverage, audience, and cost. Unlike their commercial cousins, most BCC campaigns have limited finances; therefore the selection of media becomes all the more important. If a particular medium has limited coverage, if its per-beneficiary cost is high relative to the expected impact on behavior change, or if it is of limited interest to clients, then it should not be programmed. For example, there has been a tendency on the part of BCC planners over the last three decades to use program posters, despite the fact that they are often expensive to produce, work best only in sophisticated multimedia campaigns, and provide only reminder information. A commitment to community-based, participatory programming has at times led other BCC planners to overprogram community dramas, puppetry, and folk media. These media, while
certainly of interest to individual communities, are expensive and difficult to manage on a large scale. The point is not to exclude either posters or community-based media, but to ensure that if used they are cost-effective; that is, relative to the investments in cash and management costs, they will have a significant impact on behavior change. • The design of all media should reflect the strategic principles articulated in the BCC Strategic Plan. There should be a focus only on priority messages, and each medium should respect only one unique selling principle—the communication strategy recommended in the plan. Of course, every medium is different in terms of nature and utility: A poster is simple and declaratory with striking graphics and text, a brochure provides more textual materials and some illustrations, and a community drama incorporates local folklore and traditions. Nevertheless, all media should promote the same priority practices and use the same communication strategies as presented in the plan. If a program manager, based on qualitative research and strategic planning, decides to promote immediate breastfeeding by focusing on its role in easing/hastening delivery of the placenta, this focus should be retained throughout the campaign. Although other advantages of breastfeeding may supplement this unique selling principle, the emphasis on this initial message must be maintained. Similarly, if another program chooses to focus on the nutritive qualities of breast milk, that message should be the focus throughout the BCC campaign. • The design of individual media should be based on creative thinking. Once the BCC Strategic Plan has established the priority practices to be stressed, the communication
After the Research 37
strategies to be applied, and the types of media to be programmed, program managers must then design each medium. While the qualitative research will in some cases provide useful data to guide this process (i.e., information on hopes, aspirations, expectations, concerns, fears, etc.—the staples of commercial advertising), in most cases it will not. Therefore, the program manager should recruit those communication agencies with the most creative and innovative personnel. A creative professional is one who: a) understands the audience from previous sales experience, b) can easily review, understand, and assimilate qualitative research data to glean insights about product/service appeal, and c) can follow instincts and suggest creative designs that still remain within prevailing sociocultural norms. While not every country has a highly developed advertising or marketing industry, most have professionals with at least some relevant commercial or social experience. During the competitive bidding process that characterizes most subcontracting, the program managers should be particularly attentive to the creative experience of proposed staff; this experience should be documented and available. • Media production should be as professional as possible, within cost constraints. The most creative media designs can be wasted by inferior production. Although production is often expensive, once cost-effective media have been selected, sufficient investment should be made to assure quality, attractiveness, and appeal. IPC Training The development of IPC training materials is similar to the design and development of media, for every training course should incorporate the strategic principles generated from
qualitative research and included in the BCC Strategic Plan. IPC agents are those community-based and facility-based personnel responsible for the dissemination of information about ENC. They may be doctors and nurses at a health care facility. They may be midwives or TBAs. They may be village volunteers with no health training, but with experience in health promotion. These IPC agents should be trained in the following: • Priority practices: IPC agents should fully understand which practices are to be promoted, why they are important, and how they contribute to newborn health. • Current practices: It is important for IPC agents to fully understand the current practices they are dealing with—the point of departure for behavior change. • Constraints: IPC agents must know why clients have not yet changed their behavior, and why it may be difficult to change. • Communication strategy: Community IPC agents should be trained in the communication strategies enunciated in the Strategic Plan, for it is on the basis of these strategies that they will develop individualized family behavior change programs.9 • Case histories and negotiated behavior change planning: In order to be effective in the field, every IPC worker should be trained in the essentials of taking reliable case histories—eliciting and recording information about how mothers and families have practiced ENC in the past—and in developing negotiated behavior change plans. These plans identify the degree to which a family is willing to change over a given time period; they are essential for establishing the IPC workplan.
38 Qualitative Research to Improve Newborn Care Practices
• Work planning and management: Although an IPC worker may be well trained, an essential key to ultimate behavior change is management—how to develop a reasonable and realistic workplan, and how to work effectively and efficiently within this supervisory and management plan.
Qualitative research assists program managers and researchers in developing effective, feasible, and acceptable BCC strategies to improve newborn care practices. It allows for the common or "normal" practice to be identified and the gap between that practice and the evidencebased or "best" practice to be recognized. Once the causes of this gap have been identified, the relevant constraints can be probed, understood, and finally modified. In Nepal, SNL used in-depth qualitative research findings to create a BCC strategy focusing on priority behaviors - such as delayed bathing for prevention of hypothermia- and disseminated these messages through radio vignettes, community dramas, and individual and group counseling. The midterm results of Nepal's program in the Kailali District, showing an increase in delayed bathing (for at least 24 hrs) from 7% to 68% in less than 2 years, provides an example of the insight that qualitative research can give to changing behavior, even with those practices most resistant to change. Similar success in delaying bathing has been reported in the Sylhet District of Bangladesh, after researchers undertook a well-designed formative research effort, as outlined in this guide. Pakistan's maternal and neonatal tetanus elimination program - involving the extremely effective tetanus toxoid immunization - was
not successfully implemented or utilized until the focus was taken off the campaign's logistics and put on demand creation.10 SNL's qualitative research found that the demand problem was due not only to restrictions on women's mobility, but also to lack of support by fathers, husbands, mothers-in-law, and community leaders, whose involvement turned out to be absolutely essential for the campaign. After conducting qualitative research through focus groups in two randomly selected districts, SNL took the lessons learned to design a demand-generating program where, instead of being administered by male service providers, the three doses were administered by lady health workers, door-to-door. The campaign began by raising awareness among the numerous decision-makers, and also respected the cultural norms of privacy. As a result, national coverage increased dramatically in just two years- exceeding the 80 percent target. Not every practice will, even after thorough qualitative research, be amenable to change to match the evidence-based practice, but the more aspects of essential newborn care that can be successfully integrated into the woman's and her family's decisions and actions - through the antenatal, intrapartum, or postnatal periods - the more likely that the health of the newborn and mother will improve. Moreover, change is likely to occur incrementally from current to best practices. Admittedly, qualitative research and a successful BCC strategy are only a small part of improving newborn health. Families overcoming economic, social, and informational barriers to embrace new ENC practices, though necessary, must also be complemented by knowledgeable health workers, accessible services, and adequate supplies.
After the Research 39
APPENDIX: QUALITATIVE RESEARCH RESOURCES
Directory of Qualitative Research Manuals Winch, Peter, Jennifer Wagman, Rebecca Malouin, and Garrett Mehl. January 2000. Qualitative Research for Improved Health Programs: A Guide to Manuals for Qualitative and Participatory Research on Child Health, Nutrition, and Reproductive Health. Support for Analysis and Research in Africa (SARA) project, USAID, Bureau for Africa, Office of Sustainable Development. Available from Website: <http://webdrive.jhsph.edu/pwinch/PWinch_Qual_manuals.pdf>. Qualitative Research Manuals Aubel, Judi. 1993. Qualitative Research for Improved Health Program Design: Guidelines for Studies for Using the Group Interview Technique. Development Policy Department, International Labor Office, Geneva, Switzerland. Available in English, Spanish, and French. Email: Sutton@ilo.org or Fax: (41) 22 7996111. Debus, Mary. 1988. The Handbook for Excellence in Focus Group Research. Academy for Educational Development/HEALTHCOM. Available in English, Spanish, and French. BASICS Information Center, 1600 Wilson Boulevard, Suite 300, Arlington, VA 22209. Phone: (703) 312 6800, Fax: (703) 312 6900, or Email: email@example.com; or Academy for Educational Development, 1825 Connecticut Avenue NW, Washington, DC 20009, Phone: (202) 884 8118, Fax: (202) 884 8491, or Email: firstname.lastname@example.org or email@example.com. Nachbar, Nancy, et al. Assessing Safe Motherhood in the Community: A Guide for Formative Research. 1998. MotherCare/John Snow, Inc. 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, Phone: (703) 528 7474, Fax: (703) 528 7480, Email: firstname.lastname@example.org, or Website: <http://www.jsi.com/intl/mothercare/PUBS/Assessment/cd_manual/index.htm>. Weiss, William, and Paul Bolton. Training in Qualitative Research Methods for PVOs and NGOs (and Counterparts). 2000. Center for Refugee and Disaster Studies, The Johns Hopkins University School of Public Health. 615 N. Wolfe Street, Baltimore, MD 21205. Phone: (443) 287-7277. Available from Website: <http://www.jhsph.edu/refugee/resources.html>.
40 Qualitative Research to Improve Newborn Care Practices
1. Bhutta ZA, Darmstadt GL, and Hassan B. Community-Based Interventions for Improving Perinatal and Neonatal Outcomes in Developing Countries: A Review of the Evidence. Submitted to Pediatrics (suppl.); in press. 2. Opportunity cost is the value of productive labor lost due to behavior change. 3. A prelacteal feed is a substance that is given before breastfeeding is initiated. 4. The focus of this guide is on demand. It does not address in detail the various supply factors that influence behavior change, such as the availability and accessibility of quality services, drugs, or other health products. 5. Marsh DR, Darmstadt GL, Moore J, Daly P, Oot D, and Tinker A. “Advancing Newborn Health and Survival in Developing Countries: A Conceptual Framework.” J. Perinatology 22 (2002): 572-576. 6. A skilled birth attendant is a person with midwifery skills (for example, a doctor, midwife, or nurse) who has been trained in the skills necessary to provide competent care during pregnancy and childbirth. If a woman does not have access to a skilled attendant, at a minimum she should seek an attendant trained in the evidence-based practices recommended in this guide. Based on Reduction of maternal mortality, A Joint WHO/UNFPA/UNICEF/World Bank Statement (Geneva: WHO, 1999). 7. See the Directory of Qualitative Research Manuals, in the Appendix. 8. Communication approach developed by Save the Children – is based on the assumption that negative behavior can be changed through a better understanding of the determinants of positive behavior and the translation of that understanding into BCC messages. 9. Community IPC agents should also be trained in a number of practical aspects of BCC programs such as workplanning, monitoring and evaluation, etc. 10. Ramussen, B and Ali, N. “Moblizing Demand for Maternal and Neonatal Tetanus Immunization: Reaching Women in Pakistan.” Shaping Policy for Maternal and Newborn Health: A Compendium of Case Studies (Baltimore: JHPIEGO: 2003) 23-28.
ABOUT THE AUTHORS
Ronald P. Parlato Ron Parlato has over 30 years of experience in international development, specializing in behavior change communications. At CARE India, he designed and implemented one of the first behavior change campaigns to address health and social issues through social marketing. He has been a film producer for youth media, designed and implemented formative research, and done both training and impact evaluation. He was a staff member for the World Bank in the United Nations Water and Sanitation Decade program; a Senior Development Advisor for PATH in Ukraine; and from 2001 to 2003 was the Behavior Change Advisor for Saving Newborn Lives. Gary L. Darmstadt Dr. Gary L. Darmstadt is the Senior Research Advisor for the Saving Newborn Lives initiative of Save the Children and Assistant Professor in the Department of International Health at Johns Hopkins University in Baltimore. He trained in Pediatrics at Johns Hopkins and in dermatology at Stanford University. He also completed training in pediatric infectious diseases at the University of Washington, where he was formally Assistant Professor in the Departments of Pediatrics and Medicine. His research expertise includes developing improved strategies for prevention, detection, and management of bacterial neonatal infections, and promoting healthy newborn care practices and management of illness at the community level in developing countries. Anne Tinker Anne Tinker is the Director of the Saving Newborn Lives initiative at Save the Children. She has over 25 years of experience in health and population in over 35 countries, with an emphasis on reproductive and child health. She is on leave from the World Bank, where she has been a Lead Health Specialist in the South Asia Region and the global Human Development Network, and was previously a Global Advisor on women's health and safe motherhood. She was also Division Chief in the Office of Health, USAID. She holds graduate degrees in international studies (Georgetown U.) and public health (Johns Hopkins U.). She has authored many articles and publications on women’s and children’s health.
SAVING NEWBORN LIVES Save the Children/US 2000 M Street NW Suite 500 Washington, DC 20036 www.savethechildren.org
About Saving Newborn Lives Tools for Newborn Health Series
Newborn health care poses unique problems for health professionals and program managers in developing countries, where most women deliver at home, and where health care for newborns is virtually non-existent. Improving household practices, introducing newborn health into pre- and in-service training for health workers at every level, and integrating newborn health care in the home and community with care in the facility require “fine-tuning” of established methodologies. In shaping solutions for the context of newborn health, Saving Newborn Lives has come up with innovative approaches to qualitative research, evaluation methods, behavior change communication, and training techniques that are precisely tailored to meet the challenges of institutionalizing newborn health care. The SNL Tools for Newborn Health Series is designed to share the innovative techniques used by SNL with policymakers, health professionals, and others who are working to improve newborn health care in developing countries. Volumes in the SNL Tools for Newborn Health series include: • Care for the Newborn: A Reference Manual • Qualitative Research to Improve Newborn Care Practices • Social Mobilization for MNT: Guidelines for Immunization Campaigns
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