Understanding the influence of the MomConnect programme on antenatal and postnatal care service utilization in two South African Provinces : a realist evaluation

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Stellenbosch : Stellenbosch University
ENGLISH SUMMARY: Introduction: Improvement of maternal and child health is in the 2030 agenda of the 17 Sustainable Development Goals (SDGs) where health is centrally positioned with one comprehensive goal (SDG 3), of ensuring lives and promoting well-being for all at all ages. A mobile health programme called MomConnect programme was implemented in the nine provinces of South Africa to register pregnant women and mothers, providing them with health information and education on their health and that of their babies to improve the maternal and child health in the country. Some other studies have shown the efficacy of the MomConnect programme in improving health-seeking behaviours among pregnant women and mothers. Nonetheless, there is little understanding of the contextual factors and causal mechanisms that explained these intended outcomes. To this end, a theory-driven approach to evaluate the MomConnect intervention was proposed. Methodology: The realist evaluation approach was adopted to evaluate and describe not only the intervention and its outcomes but to understand how, why, for whom and under which health system conditions, the MomConnect programme improves the health-seeking behaviours of pregnant women and mothers of infants in antenatal (ANC) and post-natal care (PNC) services in Gauteng and Free State Provinces, South Africa. And to inform guidelines on how the MomConnect can be rolled out elsewhere. The study was conducted in three different phases. In Phase one/emergent phase, the initial programme theory (IPT) of the MomConnect programme was developed using the elicitation approach. In Phase two/construction phase, we applied a multi case explanatory theory-building approach and a confirmatory theory testing approach to test the initial programme theory in four healthcare facilities, in Free State and Gauteng provinces. A cross-case analysis/in-case theories comparison was done to obtain some more refined theories. In phase three/confirmatory phase, a discussion was done with MomConnect key informants to confirm and consolidate the refined theories. Retroduction logic of making inferences was applied to configure information obtained from different sources using the intervention-context-actor-mechanism-outcome (ICAMO) heuristic tool. Results: Our initial programme theory (IPT) revealed three plausible hypotheses. The first theory assumed that a good programme designer, and health system, allow for good implementation of the programme in HCPs and increase the uptake of health services among consumers. The second theory assumed that the national department of health (NDoH) support and influence of authorities and leaders motivate healthcare providers and managers to buy-in and engage with the programme to contribute to the success of the programme by improving their performance and delivering quality maternal and child health (MCH) services. The third theory suggested that women become encouraged, empowered, and motivated, through the MomConnect health information and education to change their health-seeking behaviours and improve their health and that of their babies. After testing the initial programme theory, four different theories were refined. The first showed that MomConnect works because of a good collaboration, political clout, healthcare providers (HCPs) and clinic managers’ buy-in and willingness to work and contribute to the success of the programme by improving their performance. The delivery of MCH services is assumed to improve the health-seeking behaviours. The second refined theory showed that the programme did not work in some facilities, due to a lack of training, lack of stewardship, lack of buy-in from HCPs and clinic managers, and lack of understanding of how the MomConnect Help Desk works. The third refined theory showed that when HCPs and clinic managers perceived the NDoH’s support through training on the programme they are empowered, leading to improvement in their self-efficacy, and they become motivated and nudged to improve their performance. In the fourth theory MomConnect encouraged, empowered, and motivated women to improve their health-seeking behaviours. Our refined theories confirmed the IPTs. Conclusion: The effective implementation, sustainability, and rollout of the MomConnect mobile health programme is contingent on some important health system conditions such as availability of funding, public awareness, HCPs, and clinic managers' buy-in and engagement, and facility readiness to provide care. HCPs' workload decreases if they feel that they can get assistance when women are educated on the MCH from the MomConnect platform and get all information needed on their mobile phones from home. This makes HCPs feel less pressured to conform to their work. Also, if HCPs are satisfied with the implementation of the MomConnect programme they will engage with the programme, and their positive attitude will encourage pregnant women and mothers to use healthcare facilities and change their health-seeking behaviours. In the context of the system failure or lack of updated mechanisms, caution must be taken when registering pregnant women by explaining to them how to switch to the baby messages once they give birth, to receive the baby messages and avoid the lack of system mechanism issues.
AFRIKAANSE OPSOMMING: Inleiding: Verbetering van moeder-en-kindergesondheid is in die 2030-agenda van die 17 Volhoubare Ontwikkelingsdoelwitte (SDG's), waar gesondheid sentraal geposisioneer is met een omvattende doelwit (SDG 3), om lewens te verseker en welstand vir alle ouderdomme te bevorder. Die MomConnect-program is in die nege provinsies van Suid-Afrika geimplementeer om swanger vroue en moeders te registreer en gesondheidsinligting en opvoeding oor hul gesondheid en die van hul babas te verskaf, en om die moeder-en-kindergesondheid in die land te verbeter. Sommige ander studies het die doeltreffendheid van die MomConnect-program getoon om gesondheidsoekende gedrag onder swanger vroue en moeders te verbeter. Tog is daar min begrip vir die kontekstuele faktore en oorsaaklike meganismes wat hierdie beoogde uitkomste verklaar het. Vir hierdie doel is 'n teoriegedrewe benadering voorgestel om die MomConnect-intervensie te evalueer. Metodologie: Die realistiese evalueringsbenadering is gevolg om nie net die ingryping en die uitkomste daarvan te evalueer en te beskryf nie, maar ook om te verstaan waarom, vir wie en onder watter gesondheidstelseltoestande, die MomConnect-program die gesondheidsoekende gedrag van swanger vroue en moeders van babas in ANC- en PNC-dienste in Gauteng en die Vrystaat, verbeter in Suid-Afrika. Ook om riglyne in te lig oor hoe die MomConnect elders uitgerol kan word. Die studie is in drie verskillende fases uitgevoer. In fase een/opkomende fase is die aanvanklike programteorie (IPT) van die MomConnect-program met behulp van die elisitasiebenadering ontwikkel. In fase twee/konstruksiefase is 'n verklarende teoriebou-multi-gevallestudiebenadering en 'n bevestigende teorietoetsbenadering toegepas om die aanvanklike programteorie in vier gesondheidsorgfasiliteite, in Vrystaat- en Gauteng-provinsies, te toets. 'n Kruisgeval-ontleding, indien teoriee vergelyk word om 'n paar meer verfynde teoriee te verkry. In fase drie/bevestigende fase is 'n bespreking met MomConnect se sleutelinformant gedoen om die verfynde teoriee te bevestig en te konsolideer. 'n Retroduksielogika om afleidings te maak, is toegepas om inligting wat uit verskillende bronne verkry is, op te stel met behulp van die heuristiese instrument intervention-context-actor-mechanism-outcome (ICAMO). Resultate: Ons aanvanklike programteorie het drie aanneemlike hipoteses aan die lig gebring. Die eerste teorie veronderstel dat 'n goeie programontwerper en gesondheidstelsel goeie implementering van die program moontlik maak. Die tweede teorie veronderstel dat die nasionale departement van gesondheid (NDoH) se ondersteuning en invloed van owerhede en leier gesondheidsorgverskaffers en -bestuurders motiveer om in te koop en betrokke te raak by die program om by te dra tot die sukses van die program deur hul prestasie te verbeter en MCH-dienste van gehalte te lewer. Die derde teorie dui daarop dat vroue aangemoedig, bemagtig en gemotiveer word deur middel van die MomConnect-gesondheidsinligting en -opvoeding om hul gesondheidsoekende gedrag te verander en hul gesondheid en die van hul babas te verbeter. Nadat die aanvanklike programteorie getoets is, is vier verskillende teorieë verfyn. Die eerste het getoon dat MomConnect werk as gevolg van 'n goeie samewerking, politieke invloed, gesondheidsorgverskaffers (HCP's) en kliniekbestuurders se inkoop en bereidwilligheid om te werk en by te dra tot die sukses van die program deur hul prestasie te verbeter, word aanvaar dat die lewering van MCH-dienste die gesondheidsoekende gedrag verbeter. Die tweede verfynde teorie het getoon dat die program nie in sommige fasiliteite gewerk het nie, weens 'n gebrek aan opleiding, gebrek aan rentmeesterskap, gebrek aan inkoop van HCP's en kliniekbestuurders, en 'n gebrek aan begrip van hoe die MomConnect Help Desk werk. Die derde verfynde teorie het getoon dat wanneer HCP's en kliniekbestuurders die NDoH se ondersteuning deur opleiding op die program waarneem, is hulle bemagtig, wat lei tot verbetering in hul selfdoeltreffendheid, en hulle word gemotiveerd en aangespoor om hul prestasie te verbeter. In die vierde teorie het MomConnect vroue aangemoedig, bemagtig en gemotiveer om hul gesondheidsoekende gedrag te verbeter. Ons verfynde teoriee het die IPT's bevestig. Gevolgtrekking: Die effektiewe implementering, volhoubaarheid en implementering van die MomConnect-program is afhanklik van 'n paar belangrike gesondheidstelsel toestande soos beskikbaarheid van befondsing, openbare bewustheid, HCP's en kliniekbestuurders se inkoop en betrokkenheid, en fasiliteitsgereedheid om sorg te verskaf. HCP's se werklading neem af as hulle voel dat hulle hulp kan kry wanneer vroue vanaf die MomConnect-platform op die MCH opgelei word en alle inligting wat nodig is in hul selfone van die huis af kry. Dit laat HCP's minder onder druk voel om aan hul werk te voldoen. Ook, as HCP's tevrede is met die implementering van die MomConnect-program, sal hulle by die program betrokke raak, en die positiewe houding sal swanger vroue en moeders aanmoedig om gesondheidsorgfasiliteite te gebruik en hul gesondheidsoekende gedrag te verander. In die konteks van die stelselfout of gebrek aan opgedateerde meganismes, moet versigtig wees wanneer swanger vroue geregistreer word deur aan hulle te verduidelik hoe om oor te skakel na die bababoodskappe sodra hulle geboorte gee, om die bababoodskap te ontvang en die gebrek aan stelselmeganismeprobleme te vermy.
Thesis (PhD)--Stellenbosch University, 2023.
MomConnect programme; antenatal care; postnatal care