i ANTENATAL HEALTH COMMUNICATION: A CASE STUDY OF INFORMATION DISSERMINATION AT TEMA POLYCLINIC. BY WOELIKPLIM KOFI ELIKPLIMI (10395255) A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF A MASTER OF ARTS (M.A.) DEGREE IN COMMUNICATION STUDIES MARCH, 2015. University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I hereby declare that, this dissertation is the result of my own research work under the supervision of Professor Audrey Gadzekpo at the School of Communication Studies, University of Ghana. References made to other people’s work in this dissertation have been duly acknowledged and this dissertation has not been presented elsewhere in part or in whole for the award of another degree. Signed: ____________________ Woelikplim Kofi Elikplimi (Student) Signed: ____________________ Professor Audrey Gadzekpo (Supervisor) University of Ghana http://ugspace.ug.edu.gh iii DEDICATION This work is dedicated to the Glory of God and to my wife Sophia Mawuena Elikplimi. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT It would have been impossible to finish my dissertation without God’s grace and tender mercies. I thank Him for giving me the strength and courage to come this far. Secondly, I would like to express my deepest gratitude to my supervisor, Professor Audrey Gadzekpo for her patience to read through my work, her genuine assistance and guidance which has contributed a great deal to the value of my work. I will always be grateful to my wife and family for their priceless support throughout this course. I finally want to express my profound gratitude to Denise Duncan and all my friends who helped me in diverse ways through this journey. The good Lord bless you all. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT This study was designed to find out how antenatal health information is disseminated at the Tema Polyclinic. The study used mixed methods to collect data. Purposive sampling was also used to select three staff of Tema Polyclinic for in-depth interviews. One hundred and fifty questionnaires were distributed purposively to pregnant women out of which 115 were completed and returned. The researcher also attended antenatal health education sessions for observation. The findings of the study revealed that the face-to-face channel of communication was mostly used whereas other channels like videos and mobile phones were least used. Even though group communication and one-on-one forms of communication were generally used in the dissemination of antenatal health information, the survey showed that majority of the respondents’ preferred one-on-one form of communication to group communication. Also, though English language was generally used to disseminate antenatal health information, the survey revealed that majority of the respondents’ preferred the use of the local language to the English language. The study further revealed that there was no expert provision of communication to the hearing impaired. The study also showed that communication materials like posters, models, booklets and leaflets were used for illustrations and demonstrations in the dissemination of antenatal health information. Based on these findings, the study recommended that the least used channels of communication could be explored and the one-on-one form of communication could be increased. Apart from that, an increase in local language use in the dissemination of antenatal health information and the provision of a sign language communicator for the hearing impaired were recommended. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENT TITLE PAGE Title Page I Declaration II Dedication III Acknowledgement IV Abstract V Table of Content VI List of Tables VIII List of Figures X CHAPTER ONE 1 1.0. Introduction 1 1.1. Background of study 4 1.2. Profile of Tema Polyclinic 7 1.3. Statement of problem 8 1.4. Objectives 9 1.5. Research questions 9 1.6. Significance of Study 9 CHAPTER TWO: LITERATURE REVIEW AND THEORETICAL FRAMEWORK 10 2.0. Introduction 10 2.1. Information, Education and Communication (IEC) Concept 10 2.2. Related Studies 12 University of Ghana http://ugspace.ug.edu.gh vii CHAPTER THREE: METHODOLOGY 21 3.0. Introduction 21 3.1. Population 22 3.2. Sample Design 22 3.3. Data Collection 23 3.4. Reliability and validity of Data collection procedure 24 3.5. Data Analysis 24 3.6. Operational Definitions 25 CHAPTER FOUR: FINDINGS OF STUDY 27 4.0. Introduction 27 4.1. Age of respondents 28 4.2. Background of how antenatal health care starts 28 4.3. Communication channels 30 4.4. Communication materials 31 4.5. Forms of communication 35 4.6. Language used in disseminating antenatal health information 38 4.7. Respondents’ ability to read, write and understand English 41 4.8. Respondents’ ability to freely ask questions 42 4.9. Respondents’ ability to remember antenatal health information received 45 5.0. Respondents’ ability to work with health information received 47 5.1. Challenges in Antenatal Health Information dissemination 48 University of Ghana http://ugspace.ug.edu.gh viii CHAPTER FIVE: DISCUSSION OF FINDINGS, CONCLUSION AND RECOMMENDATIONS 50 5.0. Introduction 50 5.1. Antenatal health communication 50 5.2. Conclusions 54 5.3. Recommendations 56 5.4. Limitations of the Study 57 Bibliography 58 Appendix 64 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 1.0. Age of respondents’ 28 Table 1.1. Use of videos to share antenatal health information 30 Table 1.2. Use of mobile phones by doctors and nurses to communicate health information 31 Table 1.3. Use of posters by doctors or nurses for illustration 32 Table 1.4. Use of leaflets and booklets by doctors and nurses to share antenatal health information 34 Table 1.5. Use of models and artefacts by doctors and nurses for demonstration 34 Table 1.6. Preference for one-one sessions than group sessions 38 Table 1.7. Preference of local language use during antenatal sessions 40 Table 1.8. Indifferent about language used during antenatal sessions 41 Table 1.9. Ability to read, write and understand English 42 Table 2.0. Ability to read, write and understand local language 42 Table 2.1. Ability to ask more questions when alone with doctor or nurse 43 Table 2.2. Difficulty in asking questions during group antenatal sessions 44 Table 2.3. Freedom to ask doctor or nurse questions 44 Table 2.4. Respondents’ who easily forgot antenatal health information 46 Table 2.5. Respondents who sometimes had difficulty in understanding antenatal health information 47 Table 2.6. Ability to follow instructions and work with antenatal health information received 47 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 1.0. A sign post of Tema Polyclinic indicating the provision of antenatal health care 29 Figure 1.1. A poster on display at the antenatal health care unit 32 Figure 1.2. Illustrations on fitness for pregnancy shown on page 14 of the booklet 33 Figure 1.3. Use of models by doctors and nurses for demonstration 35 Figure 1.4. Group antenatal health education sessions 37 Figure 1.5. Photograph of the man using sign language to communicate to his wife 39 Figure 1.6. Preference of the use of local language at antenatal sessions 40 Figure 1.7. Freedom to ask doctor or nurse questions 45 Figure 1.8. Respondents’ who easily forget antenatal health information 46 University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1. 0 . Introduction Effective communication is important for proper care of women during pregnancy. This is suggests that antenatal health care officials should be able to relay antenatal health information to women in a manner that yields positive outcomes. Effective antenatal health information dissemination is needed to complete the process involved in health care delivery to pregnant women. The National Institute of Health and Clinical Excellence (NICE, 2008), in benchmarking effective communication of antenatal health information recommends some principles that are to be considered in disseminating health information. The recommendations are as follows; 1. To relay antenatal health information in a form that is easy to understand and also accessible to pregnant women with additional needs such as physical, sensory or learning disabilities and 2. To share antenatal health information in other languages considering pregnant women who do not speak or read English. 3 . To explore other forms of disseminating antenatal health information. For example, the use of audio-visual or touch-screen technology supported by written information. 4. To offer antenatal health information based on up-to-date evidence together with any support needed to enable pregnant women make informed decisions about their care. 5. To ensure that health care professionals offer consistent information to pregnant women, providing them with the opportunity to discuss and ask questions on issues about maternal health during all antenatal visits. University of Ghana http://ugspace.ug.edu.gh 2 These recommendations bring to light the importance of effectively disseminating antenatal health information to pregnant women. Beyond the provision of good health facilities, the need to explore how antenatal health information is communicated becomes relevant because lapses in this area of health communication are likely to affect antenatal health care negatively. In response to the efficacy of antenatal care and its financial and organizational implications, Banta (2003, pg. 6) indicated that antenatal care activities found to be effective should include the following; 1. Educating pregnant women about planning for safe birth 2. Informing pregnant women on emergencies during pregnancy 3. Educating pregnant women on how to deal with emergencies during pregnancy %anta’s (2003) findings speaks directly to the importance of antenatal health information dissemination as a key component in delivering effective antenatal health care. Salmon et al (2003) indicated that health communication involves the process of using mass media, events and interpersonal channels in the dissemination of messages for the purpose of promoting health to individuals, small groups, institutions, communities or nations. The process involved in health communication ass indicated by Salmon et al (2003) is useful in persuading individuals and communities to make decisions that will improve their health. For example, sending health messages through educational campaigns and other communication channels creates awareness, changes health behaviours and promotes healthy lifestyle. University of Ghana http://ugspace.ug.edu.gh 3 The World Health Organization defines antenatal health care as the process of recording details of medical history, reviewing individual needs of pregnant women, giving guidance and advice on pregnancy and delivery, screening tests, education on self-care during pregnancy and also detecting conditions that may not be favourable to health during pregnancy and offering first- line management or referral if necessary (WHO, 2003). In defining antenatal health care, the World Health Organization mentioned education on self- care during pregnancy as part of the antenatal health care process. This throws light on the importance of antenatal health information dissemination to the pregnant woman. University of Ghana http://ugspace.ug.edu.gh 4 1. 1. Background of Study The health of women during pregnancy, has received a lot of attention in recent years especially in the developing world. This attention is aimed at improving maternal health care and thereby reducing maternal mortality. The issue about women’s health during pregnancy has generated the interest of many governments and organizations across the world to the extent of influencing policy. At the global level, the Millennium Development Goal (MDG) five is aimed at improving maternal health with the target of reducing maternal mortality ratio by three-quarters between 1990 and 2015. In view this, the World Health Organization put together a work plan for antenatal health care known as the new WHO antenatal care model. This model generally sets standards for the provision of antenatal health care for women with no complications during pregnancy (WHO, 2002). The education of pregnant women about planning for safe delivery and handling emergencies during pregnancy is an integral part of :+2’s antenatal care model. The model suggests that relevant health information should be given to pregnant women from their first visit during the first trimester till their last visit in a normal antenatal care attendance. In Ghana, free antenatal care and health education interventions were introduced in 1998 under the safe motherhood programme. This was aimed at curbing maternal mortality (Biritwum, 2006, p.78). University of Ghana http://ugspace.ug.edu.gh 5 Also, the Medium-term National Development Policy framework of Ghana: Ghana Shared Growth and Development Agenda (GSGDA), makes provision for improving access to quality maternal health services by intensifying the implementation of strategies to reduce maternal mortality. This comprises the continuous provision of free health care and education for pregnant women including deliveries (National Development Planning Committee, 2010). Though there have been interventions and programmes to improve maternal health, Ghana is yet to achieve MDG five. According to the Global Gender Gap Report (2012), Ghana’s maternal mortality rate index is 350 deaths per 100,000 live births. This mortality rate is confirmed by the World Bank in its 2012 report on maternal mortality ratio in Ghana. This suggests that, interventions like free health care for pregnant women and other structural programmes like building health infrastructure, which are provided most in Ghana, may not be enough to prevent incidences of avoidable deaths recorded among pregnant women. It is therefore important to also focus much attention on other areas of maternal health that relate directly to pregnant women. The dissemination of antenatal health information is one of these areas. Disseminating antenatal health information could be a barrier to maternal health care if it is not executed effectively. The implementation of interventions to improve antenatal health normally provides solutions to identified barriers. According to the National Cancer Institute (1992) of the United States of America, barriers are considered as anything that may prevent individuals from carrying out a recommended health response. University of Ghana http://ugspace.ug.edu.gh 6 Barriers are classified as perceived or real. Perceived barriers to antenatal health for example refers to illiteracy, low self-efficacy, risk perceptions, socio-cultural norms and stigma. Real barriers on the other hand may be the lack of quality antenatal health services, accessibility to health facilities and the cost involved in accessing health facilities if they are available. Perceived barriers to antenatal health can be addressed with communication while real barriers require the use of other interventions depending on what the actual barriers are. According to the National Cancer Institute (1992) of the United States of America, communication can be used as a tool to address perceived barriers by increasing knowledge and awareness, influencing perceptions, beliefs and attitudes, demonstrating healthy practices and also showing benefits of behaviour change. This research sought to find out how antenatal health information is disseminated at Tema Polyclinic by looking out for the channels and forms of communication, and other elements of communication that are relevant and helpful in the dissemination of antenatal health information. University of Ghana http://ugspace.ug.edu.gh 7 1. 2. Profile of Tema Polyclinic This study was conducted at Tema Polyclinic. It was established as a municipal health centre in 1962 and operated for 20 years until it was upgraded to the status of a Polyclinic in 1982. It is geographically located at the south-western part of Tema and provides preventive, curative and rehabilitative health services to about 33 communities within the Tema metropolis and its environs. Tema Polyclinic provides health services to all age groups and also to all patients on the National Health Insurance Scheme (Tema Polyclinic Report, 2012). Maternal health care is among the many health services provided by Tema Polyclinic. According to the 2012 annual report of the Polyclinic, there were eight doctors and 40 clinical nurses among other staff. Many women in the Tema metropolitan area with different cultural and socio-economic backgrounds utilize the antenatal health care service of the Polyclinic. In 2012, antenatal care attendance was 18,331. In that same year, the Polyclinic recorded 1,486 deliveries which accounted for an average of 124 deliveries a month Tema Polyclinic Report, 2012). The Tema Polyclinic collaborates with the Tema General Hospital and other health care providers in the metropolis in order to provide adequate health services to the public. University of Ghana http://ugspace.ug.edu.gh 8 1. 3. Statement of problem The target of Millennium Development Goal five is to improve maternal health by reducing maternal mortality ratio appreciably by 2015. To achieve this, the new antenatal care model designed by the World Health Organization mentions education as one of the standards needed to improve antenatal health (WHO, 2002). Ghana’s 0edium-term Development Policy framework, shared Growth and Development Agenda (GSGDA), apart from the fact that it promotes the provision of free health care, also indicates education during pregnancy and delivery as a means to improve access to quality maternal health and reduce maternal mortality (National Development Planning Committee, 2010). Despite all these interventions maternal mortality is still the cause for some female deaths in Ghana. A National Development Planning Commission of Ghana and UNDP report on MDG 2008, published in 2010 indicates that the slow trends of maternal mortality reduction from 740 per 100,000 live births in 1990 to 503 per 100,000 live births in 2005, and then to 451 deaths per 100,000 live births in 2008 makes it unlikely for Ghana to meet the target of 185 per 100,000 live births by 2015. Antenatal health education which has been noted among the interventions to reduce maternal mortality requires health workers to consider efficient and innovative ways to communicate to women on care during pregnancy. Finding out how antenatal health information is disseminated in a public health facility like Tema polyclinic is relevant in examining the phenomenon. University of Ghana http://ugspace.ug.edu.gh 9 1. 4. Objectives The objective of the study sought to find out how antenatal health information is disseminated to women who utilize antenatal health care at Tema Polyclinic. 1. 5. Research questions The study sought to answer the following research questions; 1. What channels and materials are used in disseminating antenatal health information? 2. What forms of communication are used in antenatal education? 3. What languages are used to disseminate antenatal health information? 4. What are the challenges encountered in disseminating antenatal health information? 1.6 Significance of Study The importance of this is that it provided an evidence-based information on how antenatal health information is disseminated at Tema Polyclinic. Also, the outcome of the study provides information to the Polyclinic that is helpful in improving antenatal health information dissemination. It also serves as a form of communication audit report on antenatal health information dissemination. This study adds to existing literature on antenatal health information dissemination in Ghana and also forms a basis for further research. University of Ghana http://ugspace.ug.edu.gh 1 0 CHAPTER TWO LITERATURE REVIEW AND THEORETICAL FRAMEWORK 2. 0. Introduction This chapter provides a discussion on the theoretical framework that underpins the study. Some related studies on health communication are also reviewed in this chapter. These reviews pay particular attention to the context in which the study was conducted, the methods used and their outcomes. 2. 1. Information, Education and Communication (IEC) Concept The study of how antenatal health information is disseminated at the Tema Polyclinic was guided by the Information, Education and Communication (IEC) concept. The IEC concept largely draws its approach from the diffusion of innovation theory and it is defined as an approach which attempts to change or reinforce a set of behaviours in a µtarget audience’ regarding a specific problem in a predefined period of time (Clift, 2001). The diffusion of innovation theory was developed by (verett Rogers in the early ’s to e[plain how an idea or innovation gradually spreads to a specific group of people over time. According to Clift (2001), IEC strategies include planning, implementation, monitoring and evaluation. The strategies of the IEC concept contributes to the study of antenatal health information dissemination. The challenge however with monitoring and evaluation as a strategy of IEC is how the quality of an indicator can be verified against the given criteria (World Bank and Inter-American Development Bank, 2010, p. 123). University of Ghana http://ugspace.ug.edu.gh 1 1 The elements of IEC programmes in health communication are awareness creation; Knowledge increase; Influencing decisions and a Change in attitude, and moving people to adopt new behaviour or innovation (Clift, 2001). The IEC concept also considers the mass media, interpersonal and group communication channels and feedback mechanisms as strategies that could be adopted in diffusing health information effectively. Similarly, this study questioned the Channels and forms of communication used in disseminating antenatal health information at the Tema Polyclinic. The considerations of the IEC concept further serves as a guide which underpins the study of how antenatal health information is disseminated at the Tema Polyclinic. Again, Clift (2001), lays emphasis on the need for a strategic approach to partnerships aimed at improving the delivery of health and communication programmes. Further, the characteristics of the IEC concept explore how people are influenced by the testimonies of others before they are compelled to adopt behaviour change and how the use of fear is rarely effective in convincing people to adopt change. The main challenge of IEC interventions are limited resources and unrealistic expectations (Clift, 2001). The relevance of the IEC model to the study was that it served as a guide to explore how antenatal health information is disseminated and used to educate pregnant women. The study also explores the challenges of antenatal health information dissemination at Tema Polyclinic against the challenges of the IEC model. University of Ghana http://ugspace.ug.edu.gh 1 2 2. 2. Related Studies Kwapong (2008) in an article on the health situation of women in Ghana, pointed out that the adoption of a multi-sectorial approach in health interventions is strategic in improving the health of Ghanaian women. She mentioned the use of information, communication and education (IEC) materials as a strategic intervention that could contribute a great deal to advocacy efforts in improving women’s health. She also stated that educational efforts, whether formal or informal adult education should be intensified and used as a tool to create awareness as it provides a leverage for women at all levels in the implementation of interventions to improve the health of women in Ghana. The highlights on the use of IEC materials to create awareness as indicated in by Kwapong in her article resonates with the some of the objects of IEC programmes which are awareness creation, increase knowledge and behaviour change. The study of antenatal health information dissemination at the Tema Polyclinic also explores the materials used in antenatal health education. Another study was conducted in Ghana by Bansah et al (2007) to explore the perceived antenatal learning needs of 18 Ghanaian women who were between 38 and 40 weeks of their gestation without complication. These women had been pregnant multiple times at a hospital in Accra where the study was done. In-depth interviews, semi-structured interviews and a single focus group were adopted in this study. University of Ghana http://ugspace.ug.edu.gh 1 3 It was found that during antenatal care sessions, women expressed the need for information on birth control, sexual activity during pregnancy and preventing fatal positions during pregnancy. They also sought for information on how to care for themselves and their babies after birth. It was also found that the information received by pregnant women from antenatal sessions was inconsistent with what they received from their mothers and friends. One-on-one private counselling sessions and other information dissemination strategies were proposed to address the concerns of these women. The IEC model provides appropriate benchmarks for addressing the issue of inconsistent antenatal health information as noted in this study. When proper implementation, monitoring and evaluation, as suggested by the IEC model, is incorporated in the antenatal health communication process, the issue of inconsistent antenatal health information is addressed. Again, '’Ambruoso et al  conducted a study in Accra to find out the perceptions and experiences of pregnant women in terms of factors that influenced place of delivery, satisfaction with services, and expectations of care and whether they would recommend the services they received. This study involved 21 in-depth interviews and two focus group discussions with women who had given birth in the last five years. One of the components of care that turned out to be the expectation of women before and during delivery is how well the health care providers related to them. This determined whether they were satisfied or not with the provision of health care. University of Ghana http://ugspace.ug.edu.gh 1 4 The study revealed that pregnant women were satisfied with health care providers with good interpersonal skills who related to them well. The study of antenatal health information dissemination at the Tema Polyclinic also explored the forms of communication used in disseminating antenatal health information. The IEC model also considers interpersonal communication as one of the strategies in diffusing health information effectively. Similar to '’Ambruoso et al  study, Pell et al (2013) also conducted a study that explored the factors that influence antenatal health care attendance in Ghana, Kenya and Malawi. They used interviews, focus groups and observations in local communities and health facilities. Their findings suggested that in the midst of social and cultural diversity, the factors that influenced women’s attendance of antenatal health care sessions related to the response they get in terms of antenatal health communication. An e[clusive factor that influenced women’s timing for starting antenatal health sessions was traced to the interactions they had with health workers mostly on messages about timing of antenatal health care. The IEC model as part of its strategy also uses communication to influence decisions and change health behaviour. Montasser et al (2012) also conducted a similar study in Egypt. They used a cross sectional descriptive approach to find out (gyptians women’s perception of antenatal care. The study engaged 600 pregnant women attending antenatal care clinic in Shawa centre from March 2010 to September 2010. They used face to face interviews and a well-structured questionnaire for data collection. University of Ghana http://ugspace.ug.edu.gh 1 5 They found out that 23.3 percent of the pregnant women were satisfied with health education programs in general and 37.5 percent were satisfied with the doctor’s e[planation of the benefits of antenatal health care. Their study also revealed that 64.2 percent of the women were satisfied with the doctor’s explanation about safe effort during delivery. The general outlook of this study shows the adoption of interpersonal communication as a predominant option in disseminating antenatal health information. The IEC concept relates to this study in terms of providing interpersonal communication as a strategic option for antenatal health information dissemination among others. Apart from this, Anya et al (2008) also did a study on how information and education are provided in antenatal clinics from the perspective of pregnant women attending these clinics in Gambia. They used a cross sectional survey method and conducted exit interviews. They also used the antenatal record review questionnaires from the WHO Safe Motherhood Needs Assessment kit and administered it to 457 pregnant women in twelve different clinics. The study showed that though 99 percent of those interviewed attended antenatal clinic, only 52 percent of the pregnant women attended four or more times. The percentage of women who remembered the information they received through antenatal health education were less than 35 percent and 70.5 percent of the women noted that they spent three minutes or less with the antenatal care provider. University of Ghana http://ugspace.ug.edu.gh 1 6 The study attributes the increasing maternal mortality ratio in Gambia on poor information, education and communication during antenatal care. A well planned, implemented, monitored and evaluated IEC have a high tendency of reducing maternal mortality ratios. In a district hospital in Malawi, Kumbani et al (2012) conducted a study to find out whether or not Malawian women critically access quality of care. They used face-to-face in-depth interviews with semi structured interview guides to collect data on women’s perception on antenatal health care. Even though participants did not relate the dissemination of health information to care, they acknowledged that they received different health information during group health education. The study emphasized the need to standardize the dissemination of antenatal health information and placed the responsibility of its effectiveness on health workers In a similar study, Nikiema et al (2009) did a cross-sectional, cross-country analysis on data from the most recent demographic and health surveys to explore the provision of information on pregnancy complications during antenatal visits in 19 countries in Sub-Saharan Africa. They found out that the percentage of women recalling information about potential complications of pregnancy during antenatal care varied widely, ranging from 6% in Rwanda to 72% in Malawi, and in 15 of the 19 countries, less than 50% of women reported receiving information. The study identified some barriers that prevented the women from accessing antenatal health care and recommended health care providers to utilize every opportunity to educate pregnant women as it plays a key role in safe motherhood initiatives. University of Ghana http://ugspace.ug.edu.gh 1 7 The study concluded that there is a high level of unmet need for information on pregnancy complications in sub-Saharan Africa, particularly among those who face significant barriers to accessing care if complications occur. This conclusion can be addressed with the use of awareness creation which is one of the strategies of the IEC model. Also, 500 women living at Jinja in Uganda were interviewed by Sangaré et al (2012). The purpose of the interviews was to find out what determined the use of insecticide treated nets (ITN) for malaria prevention during pregnancy. These women had been pregnant in the past year and random sampling was used to select them for the interview. ITN ownership at the start of pregnancy was reported by 359 women (72%) and 28 women (20%) acquired an ITN after the first trimester of pregnancy. Among 387 ITN owners, 73% reported either always sleeping under the ITN during all trimesters of pregnancy, or after acquiring their net. The study also revealed that women who always slept under insecticide treated nets were likely to have been influenced advertisement on radio or posters rather than being given an insecticide treated net free of charge. Considering the result of this study, the use of communication materials and the mass media which are all components of the IEC model will help to deliver effective antenatal health information is dissemination. Furthermore, Bbaale (2011) examined the factors influencing timing and frequency of antenatal care, using data from the Uganda Demographic and Health Survey (UDHS) for 2006. The descriptive and quantitative approach were used in this study. The study showed that only 17 percent of mothers started attending antenatal care sessions within the first three months of pregnancy and 47 percent had at least four antenatal visits during pregnancy. This result was influenced by women’s education on antenatal health care and their access to the media. University of Ghana http://ugspace.ug.edu.gh 1 8 The study recommended that the educating girls beyond secondary school level and increasing media penetration amongst the population should be used to make antenatal health information accessible to women. This recommendation agrees with the research findings of Sangaré et al (2012) about how radio advertisement and posters influenced pregnant women to use ITN’s rather than being given ,71’s free of charge. In another related study, Gross et al (2012) examined the timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania. The purpose of the study was to find out the reasons for early and late antenatal attendance. Qualitative exploratory studies informed the design of a structured questionnaire which was administered to 440 women in exit interviews after attending antenatal care. It was discovered that most of the women on the average started attending antenatal care after the fifth month of pregnancy. This was due to lack of awareness about the health benefit of antenatal care. The objects of the IEC concept which include creating awareness and increasing knowledge among others will serve the purpose of effective dissemination of antenatal health information in this circumstance. Similarly, Raine et al (2010) conducted a qualitative study of women’s e[periences on communication in antenatal health care in the United Kingdom to find out features of communication that are seen as positive or negative. The communication experiences of 30 women were examined by using focus groups and semi-structured interviews at a hospital in London. Data were analysed using thematic analysis. University of Ghana http://ugspace.ug.edu.gh 1 9 Among the many experiences reported, the main features of poor communication pointed out were lack of information provision in the following areas; 1. The overall arrangement and the purpose of antenatal care 2. Insufficient discussion about possible problems pregnancy 3. Discourteous styles of interaction by antenatal health care providers The study recommended communication training for antenatal health care providers to promote a friendly provider-user relationship and also encourage the pregnant women to participate fully in antenatal sessions and access the care they need. The features of poor communication reported by the pregnant women affirm the need to use IEC programmes to make strategic contributions to antenatal health information dissemination in providing the requisite training to health care workers. In another study by Tsianakas and Liamputtong (2002) an in-depth interview was conducted with 15 Islamic women living in Melbourne on their perceptions and experiences of antenatal care. The study showed that there was insufficient communication between health care providers and pregnant women. This was attributed to language barrier and lack of cultural appreciation among health care providers. The study indicated that the cultural backgrounds of pregnant women and the issue of language are critical in disseminating antenatal health information. Finally, Comrie et al (2010) conducted a study on µ&ommunicating ,nfant ,mmuni]ation Resource 'evelopment and (valuation’. They worked with end-users and key community groups to develop and test resources to communicate information about infant immunization to expectant mothers. University of Ghana http://ugspace.ug.edu.gh 2 0 They had a number of focus group discussions with end-users and health professionals to develop end-user directed infant immunization communication resources. They did a pilot trial of the resources on an intervention group and a control group made up of expectant mothers. The intervention group saw flipcharts and other communication resources with an oral presentation of salient points and the control group only heard oral presentation. These expectant mothers were interviewed later in their ninth month and two months after giving birth respectively. It was found out that the women who were in the control group, at the postnatal interview had little or no recall of the information they had received early on. However, the women in the intervention group were mostly confident and remembered the information given to them. This study shows that the use of flip charts and other communication materials or resources are helpful in disseminating antenatal health information. The relevance of the IEC model is highlighted in this study as the use of communication materials form part of its strategies. University of Ghana http://ugspace.ug.edu.gh 2 1 CHAPTER THREE METHODOLOGY 3. 0. Introduction This chapter is a discussion on how the research was carried out. Rajasekar et al (2006) classify research methodology as the orderly manner by which research problems are tackled or the skill of carrying out research. The case study method was used to explore how antenatal health information is disseminated at Tema Polyclinic. Yin (1994) indicates that the case study method is used to address research questions that seek to answer µhow’ or µwhy’ the e[tent of control over behavioural events, without the influence of the researcher on the general circumstance(s) of the real-life phenomenon. Bromley (1986) also defines case study as a µsystematic inquiry into an event or a set of related events which describe and explain the phenomenon of interest’. He indicates that the unit of analysis may vary from an individual to a corporation. In this study, the researcher combined both quantitative and qualitative data collection methods known as triangulation. According to Patton (2001) as cited by Golafshani (2003) triangulation refers to the combination and usage of several varieties of methods or data, including quantitative and qualitative approaches to strengthen a study. A quantitative approach was used to collect data from pregnant women at the Tema polyclinic. Also, in-depth interviews were conducted with three members of staff at the hospital and the researcher attended antenatal health education sessions to observe and take notes. University of Ghana http://ugspace.ug.edu.gh 2 2 3. 1. Population Creswell (2012) describes population as any group of individuals who have one or more characteristics in common that are of interest to a researcher. According to him, the population may be all the individuals of a particular group or a more restricted part of that group. The target group for this study was drawn from the population of health care providers and pregnant women accessing antenatal health care at the Tema Polyclinic. 3. 2. Sample Design Two different groups of population were sampled purposively. The first sample was made of 150 pregnant women who were given questionnaires to complete. Sample selection of pregnant women was done purposively because of their varying moods and conditions. This made it impossible for all the pregnant women to participate in the exercise. In-depth interviews were conducted with the second sample which comprise three members of staff of the Tema Polyclinic. They are, the administrator and public relations officer, the head of antenatal care unit and a health care nurse. They were also selected purposively because of their role and expert knowledge in antenatal health care. Kerlinger (2007) explains sampling to mean any portion of a population or universe that represents the entire population or universe. Similarly, Wimmer and Dominick (2011) also consider a sample to be a subset of a population that represents the entire population. Oliver (2006) furthermore indicated that purposive sampling is a form of non-probability sampling where the researcher takes into consideration the expert knowledge of participants on the research area or the willingness and availability of the participants in sample selection. University of Ghana http://ugspace.ug.edu.gh 2 3 %efore the researcher embarked on the study the consent of the 3olyclinic’s administrator was sought for permission to conduct the study at the Polyclinic. The authority of the Polyclinic permitted the researcher to conduct the study and asked the matron in charge of the maternal health unit to provide the researcher with the necessary assistance. An average of 66 pregnant women attended antenatal health education sessions each day from Monday to Friday, making a total of about 330. Purposive sampling approach was used to select 30 women each day from Monday to Friday which provided a total of 150 women to represent the entire population. The researcher attended antenatal health education sessions to observe and take note. At each session the pregnant women were informed of the researcher’s presence and assured them that data collected was purely for academic purposes only. 3. 3. Data Collection The researcher collected data through the following sources: 1. In-depth Interviews ± Legard et al (2003) refers to in-depth interviews as an unstructured data collection method which is responsive, flexible and an interactive questioning technique used in in-depth data collection. 2. Questionnaires ± The researcher designed questionnaires to elicit information from pregnant women about how antenatal health information is disseminated. The questionnaires contained 18 closed end questions each with a µ<(6’ or µ12’ option. 3. Observation ± The researcher attended three antenatal health education sessions at the Tema Polyclinic to observe and take notes on how antenatal health information is disseminated. Erlandson et al (1993) indicated that observations helps the researcher to describe the existing situations using the five senses, providing a "written photograph" of the situation under study. University of Ghana http://ugspace.ug.edu.gh 2 4 Yin (2003), noted that, a mark of case study research is the use of multiple data sources. According to him, it is a strategy which also enhances data credibility. Data sources for case study research include documentation, archival records, interviews, physical artefacts, direct observations, and participant-observation (Baxter and Jack, 2008). 3. 4. Reliability and validity of Data collection procedure To fulfil the objectives of the study, the questionnaire was made simple and easy to understand. The initial questionnaire was pretested during one of the antenatal sessions at the Tema Polyclinic prior to the study. This was done to ensure that the questions were relevant and provided the required data. The question guide used for the in-depth interviews posed questions that were related to the research questions. The in-depth interviews were captured by the researcher with an audio recorder to ensure reliability. Golafshani (2003) mentioned that the extent to which results are consistent over time and the accurate representation of the total population under study is referred to as reliability. He added that the results of such study should be able to be reproduced under a similar methodology. He also noted that the trustworthiness of a research report establishes the reliability and validity of a study in qualitative research. 3. 5. Data Analysis The questionnaires administered were also collected from the respondents after they were completed. Out of 150 questionnaires distributed, 115 were completed and returned. The completed questionnaires were labelled from one to 115 and the answers to each question on each questionnaire was coded manually. The labelled and coded questionnaires were entered into a data set known as µ6tatistical 3ackage for 6ocial 6cientists’ 6366 software. University of Ghana http://ugspace.ug.edu.gh 2 5 The SPSS software programme was used with the help of a computer to analyse and present the data in pie charts and graphs to make sense out of the data for easy understanding. Analysing qualitative data starts from the point of data collection through to the end. Wimmer and Dominick (2011) indicate that explanations are made out of qualitative data when they are grouped into suitable categories and themes. A report was also written out of the notes from the observations made during antenatal health education sessions. All the data collected from the various sources were integrated in the analysis. 3. 6. Operational Definitions 1. Antenatal health care: In the study, antenatal health care refers to any form of care, support and advice given to pregnant women before the delivery of their babies. 2. Information dissemination: It refers to how messages are sent from one person to the other or to a group of individuals. 3. Health education: It is the process of professionally relaying health information to people with the aim of creating awareness, increasing knowledge or adopting a behaviour. 4. Health communication: It is a process that uses mass media, events and interpersonal channels in the dissemination of messages for the purpose of promoting health either to individuals, small groups, institutions, communities or nations. 5. Communication materials: For the purpose of the study, communication materials refers to posters, flyers, brochures, leaflets, models and any material used for demonstrative purposes. University of Ghana http://ugspace.ug.edu.gh 2 6 6. Types of communication: In the study, reference to types of communication is limited to group communication and one-on-one or face-to-face communication. University of Ghana http://ugspace.ug.edu.gh 2 7 CHAPTER FOUR FINDINGS OF STUDY 4.0. Introduction This chapter provides information on the findings of the study. The study set out to find out how antenatal health information is disseminated at Tema Polyclinic. In-depth interviews were conducted with three members of staff of the Polyclinic from 18th to 20th February 2015. This was done by interviewing three staffs of Tema Polyclinic. The staff interviewed were, the administrator and public relations officer, the head of antenatal care unit and a nurse at the antenatal health care section. All the in-depth interviews were done in the respondent’s offices. The researcher used a digital recorder to record the in-depth interview. The recordings were later transcribed and discussed thematically. In addition to this, the researcher conducted a survey and also made some observations during antenatal health education sessions. The findings made from the in-depth interviews, survey and observations were presented under the following themes: 1. Age of Respondents 2. Background on how antenatal health care starts 3. Channels of communication 4. Communication materials 5. Forms of communication 6. Language used in disseminating antenatal health information 7. Respondents’ ability to read and write 8. Respondents’ ability to ask questions freely University of Ghana http://ugspace.ug.edu.gh 2 8 9. Respondents’ ability to remember health information received 10. Respondents’ ability to work with health information received 11. Challenges with antenatal information dissemination 4.1 Age of Respondents The survey revealed that majority of the respondents’ who attended antenatal sessions in the course of this study particularly at the time of data collection were below 30 years of age. As indicated in Table 1.0 below, 70 respondents’ said they were below 30 years while 45 respondents’ were older than 30 years. Table 1.0. Age of Respondents ’ below 30 years Response Frequency Percentage YES 70 60.9 NO 45 39.1 TOTAL 115 100.0 4.2 Background on how antenatal health care starts The administrator and public relations officer stated in her interview that, Tema Polyclinic is a public health facility and operates by the protocols of the Ghana health service. According to her, women walk in sometimes to the general out-patient department (OPD) for general check- up or to confirm pregnancy. They are then taken through the routine and required medical examination. University of Ghana http://ugspace.ug.edu.gh 2 9 When pregnancy is confirmed, the woman is encouraged to register for the National Health Insurance Scheme (NHIS) because of the free maternal care policy under the scheme. The woman is then given an appointment depending on the age of the pregnancy and also given a pink book which contains antenatal health information. At this stage communication is mostly verbal. The in-depth interview revealed that, at the first contact women are engaged on on-on-one basis in an interview. During this interview, they mostly open up and share their anxieties and suspicions of being pregnant. Series of laboratory tests are conducted to confirm pregnancy and also find out the possibility of complications. The antenatal care nurse said that during the interview, the tests results helps them to manage the pregnant woman by providing the necessary and relevant care until she is due for delivery. Apart from women who walk in to confirm pregnancy, it was also recounted that during community health education activities, community health nurses sometimes find it necessary to refer women to the Polyclinic if they are suspected to be pregnant and have not reported to any health facility. Figure 1.0. A sign post of Tema Polyclinic showing antenatal health care service University of Ghana http://ugspace.ug.edu.gh 3 0 4.3 Channels of communication In response to the channels used in communicating antenatal health information at Tema Polyclinic, the administrator and public relations officer indicated that though the main channel used is face-to-face, videos on antenatal care are sometimes shown to pregnant women. The researcher however did not witness the use of videos in sharing antenatal health information during his observations. 6imilarly the antenatal health nurse also said ³, have never seen videos being shown during antenatal sessions´. The antenatal health care unit contacts and follow-up pregnant women via text messages or phone calls if the need arises. They also take records of the phone numbers and alternative contact numbers of the partners of pregnant women so as to reach them at all cost. It was noted that the nurses at the antenatal health unit preferred phone calls to text messages because the messages were sometimes misinterpreted. The head of the unit recounted that they sometimes use mobile phone applications like ³:hatsApp´ to share antenatal health information as some of the pregnant women communicate to them through that means. The survey indicated that majority of the respondents’ did not witness the use of videos as a channel of sharing antenatal health information. As shown in Table 1.1 below, 101 respondents’ said videos were not used as a channel of communication. Table 1.1. The use of videos to share antenatal health information Response Frequency Percentage YES 14 12.2 NO 101 87.8 TOTAL 115 100.0 University of Ghana http://ugspace.ug.edu.gh 3 1 With regards to the use of mobile phones as a channel of communication, the survey showed that 100 respondents’ said the doctors and nurses did not use mobile phones to communicate with them. Only 15 respondents’ said mobile phones were used to communicate with them as shown in Table 1.2 below. Table 1.2. Use of mobile phones by doctors and nurses as a means of communicating health information Response Frequency Percentage YES 15 13.0 NO 100 87.0 TOTAL 115 100.0 These findings show that though videos and mobile phones were mentioned as channels used to disseminate antenatal health information only few pregnant women had been contacted via these channels of communication. 4.4. Communication materials The in-depth interviews revealed that illustrative posters are used to disseminate antenatal health information. The posters used at the antenatal care unit are pictorial with only a few text. It was noted that some of the women were unable to read and write so the illustrative posters were effective in giving them a visual idea of the message they carry. It was also mentioned during the in-depth interview that some of the posters were on malaria prevention for pregnant women, tetanus immunization, family planning, breast feeding and so on. University of Ghana http://ugspace.ug.edu.gh 3 2 Though the researcher did not see posters being used to share information during antenatal education sessions, a poster on breastfeeding and a few others were mounted on the walls of the room where antenatal sessions were held. Fig. 1.1. A poster on display at the antenatal health care unit The survey revealed that 60.9 percent of the respondents’ said posters were used for illustration at antenatal health education sessions. As shown in Table 1.3 below, only 39.1 percent of the respondents’ said posters were not used for illustration. Table 1.3. Use of posters by doctors and nurses for illustration Response Frequency Percentage YES 70 60.9 NO 45 39.1 TOTAL 115 100.0 University of Ghana http://ugspace.ug.edu.gh 3 3 Apart from the use of posters, the in-depth interview revealed that leaflets and booklets containing antenatal health information were given out to pregnant women. The antenatal health care nurse said that: ³«when they come we find out if they are able to read and write. )or those who are not able to read and write we normally don’t give them the booklet. :e read through and e[plain it to them. Sometimes too, we give it out to them and tell them to take it home and get someone who can read to assist them´. Though the researcher did not witness the distribution of leaflets or booklets at any of the antenatal sessions he attended, he was given a copy of one of the booklets they give to the pregnant women upon his request. 7he booklet is titled ³:hat (very 3regnant :oman 6hould .now´. 7he front cover of the booklet is green and it has 24 pages. The antenatal health information in the booklet was put together by the Ministry of Health (MOH) and Ghana Health Service Reproductive and Child Health Department. Fig 1.2 Illustration on fitness for pregnancy shown on page 14 of the booklet University of Ghana http://ugspace.ug.edu.gh 3 4 The survey revealed that 78 respondents’ said leaflets and booklets were used by doctors and nurses to share antenatal health information. As shown in Table 1.4, only 37 respondents’ said leaflets and booklets were not used to share antenatal health information. Table 1.4. Use of leaflets and booklets by doctors and nurses to share health information Response Frequency Percentage YES 78 67.8 NO 37 32.2 TOTAL 115 100.0 It was also mentioned during the in-depth interview that models and artefacts were used during antenatal health education for demonstration. This is intended to help pregnant women have a better understanding of the antenatal health information being shared. The head of the antenatal health unit mentioned that though some of the models and artefacts needed were not available, they used improvised ones as it is easier for most of the women to understand what they communicate it they use models and artefacts for demonstration. The survey showed that 51.3 percent of the respondents’ said the doctors and nurses used models for demonstration while 48.7 percent of the respondents’ disagreed. Table 1.5 indicates that almost half of the respondents’ said models and artefacts were not used for demonstration. Table 1.5. Use of models and artefacts by doctors and nurses for demonstration Response Frequency Percentage YES 59 51.3 NO 56 48.7 TOTAL 115 100.0 University of Ghana http://ugspace.ug.edu.gh 3 5 Fig. 1.3. 4.5 Forms of communication The researcher noted during the in-depth interview that group and on-on-one communication are the two forms of communication used to disseminate health information at the Tema Polyclinic. Group communication was mostly used in the past until the introduction of ³)ocused Antenatal´ which is aimed at improving maternal health. 7he administrator and public relations officer said that: ³«now we have focused antenatal. 3reviously it was mostly mass education. 1ow we have cubicles for that and apart that, from the general information dissemination that is ongoing. The one-on-one helps the antenatal nurses and doctors to attend to particular needs of the pregnant woman´. University of Ghana http://ugspace.ug.edu.gh 3 6 Both the group and on-on-one forms of communication were done throughout the week from Monday to Friday. The group antenatal health education sessions are held in the mornings from 8am followed the one-on-one sessions which are done in the cubicles. During the group sessions, the women are taken through series of physical exercises. After that, demonstrations are used a lot to further explain the information being shared. The head of the antenatal care unit said that: ³:e do group communication but individuali]ed communication or what we call focused antenatal that is one-on-one is done when you get into the cubicle but when we are outside we give them brief education and do e[ercise and demonstrations´. Also, time is allotted for questions during group sessions. The nurses ask questions to find out whether information shared during the previous meetings were well understood. The pregnant women are also given the opportunity to ask questions for clarity on any issue bothering them. The in-depth interview revealed that the pregnant women are more comfortable with the focused antenatal sessions because they are able to open up and ask more questions. The researcher witnessed three group antenatal education sessions ant the nurses who handled these sessions were very interactive and friendly. There were demonstrations on how a pregnant woman should walk and bend, and all kinds of exercises a pregnant should do to be in good shape. The researcher witnessed an exciting singing and exercise session led by the nurse on duty and all the pregnant women were happily involved. The nurses were very humorous and very engaging. They also discussed how to prepare for delivery, the signs to look out for when labour starts and many more. Figure 1.4 shows one of the group education sessions. University of Ghana http://ugspace.ug.edu.gh 3 7 Fig. 1.4. The researcher also observed that there were five cubicles used for the one-on-one sessions. This session is called focused antenatal. After the group session, the women were called in turns to meet the doctor or nurse in the cubicle. The in-depth interview revealed that once in every quarter they held a group antenatal education session called ³'addy’s clinic´. 7he head of the antenatal unit said that ³«this is also called husbands’ pregnancy school. ,t starts at pm to suit the husbands as they will be on lunch break. ,t’s something that the Ghana Health Service want all health institutions to be doing but the style depends on the individual health institution or facility as it is the wish of the Health Service to involve husbands in pregnancy and delivery to improve maternal health´. The survey revealed that majority of the respondents’ preferred one-on-one antenatal health sessions to the group sessions. Only a few of the respondents’ preferred the group to the one- on-one sessions. As show in Table 1.6 below, 76.5 percent of the respondents’ preferred one- on-one antenatal health sessions while 23.5 percent preferred the group sessions. University of Ghana http://ugspace.ug.edu.gh 3 8 Table 1.6. Preference for one-on-one sessions to group sessions Response Frequency Percentage YES 88 76.5 NO 27 23.5 TOTAL 115 100.0 4.6. Language used in disseminating antenatal health information The in-depth interview revealed that English language is mostly used to disseminate antenatal health information. It was recounted that interpretation of the English language is done when it becomes necessary to do so. According to the antenatal care nurse, interpretation from the English language to the local languages was possible because some of the nurses at the antenatal unit were able to speak Ga, Twi Ewe and some of the other local languages. Among the local languages, Twi was widely used in disseminating antenatal health information. It was also revealed that only a few respondents preferred the English language while Ga and Ewe were used as the need arises. In finding out whether the doctors were able to conveniently express themselves in the local language, the antenatal health nurse said that: ³«sometimes it is a challenge but not a big one. 7he doctors work with the nurses and the midwives and there will always be someone to assist them. In Ghana people are able to speak two or more different languages and from experience we have been doing well with the Twi and Ga´. University of Ghana http://ugspace.ug.edu.gh 3 9 The researcher made an interesting observation when he joined one of the antenatal education sessions. There was a hearing impaired pregnant woman who was actively part of that session with the help of her husband. The man used sign language to communicate the antenatal health information that was being shared to his hearing impaired wife. Figure 1.5 is a photograph of the man using sign language to share health information being shared to his wife. Fig. 1.5. The survey showed that even though English was generally used in disseminating antenatal health information, majority of the respondents’ preferred the use of the local language in the dissemination of antenatal health information. As shown in 1.7, as many as 100 respondents’ preferred the use of the local language while only 15 respondents’ preferred the use of English language. University of Ghana http://ugspace.ug.edu.gh 4 0 Table 1.7. Preference of the use of local languages at antenatal sessions Response Frequency Percentage YES 100 87.0 NO 15 13.0 TOTAL 115 100.0 Below in figure 1.6 is a frequency bar chart showing the preference of local language use during antenatal health sessions. Fig. 1.6. Even though 87 percent of the respondents’ preferred the use of local language at antenatal health sessions, 80.9 percent of the respondents’ were indifferent. As shown in Table 1.8, only 19.1 percent of the respondents’ were particular about the language used. University of Ghana http://ugspace.ug.edu.gh 4 1 Table 1.8. Indifferent about language used during antenatal health education Response Frequency Percentage YES 93 80.9 NO 22 19.1 TOTAL 115 100.0 4.7. Respondents ’ ability to read and write The in-depth interviews revealed that no survey has been conducted to give accurate figures on the percentage of pregnant women who are able to read and write and those who are unable to do so. It was recounted that about 60 percent of the pregnant women who access the antenatal health service of the Tema Polyclinic were semi literates. It was revealed that the nurses find out whether the pregnant women are able to read and write. According to the antenatal care nurse, the response helps them (in the case of the pregnant woman’s inability to read and write to provide specialised care in terms of ensuring that the antenatal health information shared is well understood. In such cases, they read through antenatal health booklets and leaflets with the women and also provide further explanations where necessary. The survey showed that majority of the respondents’ were able to read and write while only a few respondents’ were unable to do so. Table 1.9 indicates that 92 respondents’ were able to read, write and understand the English language while 23 respondents’ admitted that they were unable to do so. University of Ghana http://ugspace.ug.edu.gh 4 2 Table 1.9. Ability to read, write and understand English Response Frequency Percentage YES 92 80.0 NO 23 20.0 TOTAL 115 100.0 Also, more than half of the respondents’ acknowledged that they are able to read, write and understand their local language. As shown in Table 2.0 below, 72 respondents said they are able to read, write and understand their local language while 43 respondents’ admitted that they were unable to do so. Table 2.0. Ability to read, write and understand local language Response Frequency Percentage YES 72 62.6 NO 43 37.4 TOTAL 115 100.0 4.8. Respondents ’ ability to freely ask questions During the in-depth interviews, it was stated that at the beginning and closing of group antenatal education sessions, the women were given opportunity to ask questions. This was intended to help the antenatal care unit receive feedback from the women. University of Ghana http://ugspace.ug.edu.gh 4 3 The head of the antenatal care unit said that: ³«at times we even start with them in the morning before we do the general talk. We ask them what they learnt at our previous meeting and they tell us. :hen we finish with the day’s session they talk to us about their problems and share what they didn’t understand. At times some come back with further questions and this helps to know when their condition is deviating from the normal´. The researcher observed that even though women were given the opportunity to ask questions during group antenatal sessions, only a few of them kept asking questions. Most of the women were reluctant to ask questions. The survey indicated that majority of the respondents’ were able to ask questions during the one-on-one sessions rather than the group sessions. As shown in Table 2.1 below, 94.8 percent of the respondents’ said they were able to ask a lot of questions during the one-on-one sessions either with the doctor or the nurse. Table 2.1. Ability to ask more questions when alone with doctor or nurse Response Frequency Percentage YES 109 94.8 NO 6 5.2 TOTAL 115 100.0 Less than half of the respondents’ admitted that they found it difficult to ask questions during antenatal sessions. As shown in Table 2.2, 54 respondents’ said that it was difficult for them to ask questions at group antenatal sessions while 61 respondents’ said it was not difficult for them to do so. University of Ghana http://ugspace.ug.edu.gh 4 4 Table 2.2. Dif ficulty to ask questions during group antenatal sessions Response Frequency Percentage YES 54 47.0 NO 61 53.0 TOTAL 115 100.0 Despite the difficulty of some women to ask questions during group sessions, 93 percent of the respondents’ acknowledged that they are generally free to ask the doctor or nurse questions while only seven percent said otherwise. This affirms that the antenatal care unit gives the women opportunity to ask questions and give feedback. As shown in Table 2.3, 107 respondents’ said that they had the freedom to ask the doctor or nurse questions while only eight respondents’ disagreed. Table 2.3. Freedom to ask doctor or nurse questions Response Frequency Percentage YES 107 93.0 NO 8 7.0 TOTAL 115 100.0 University of Ghana http://ugspace.ug.edu.gh 4 5 Below in figure 1.7 is a pie chart a pie chart (in percentage terms) that shows respondents’ admission of their freedom to ask doctor or nurse questions. Fig. 1.7. 4.9. Respondents ’ ability to remember antenatal health information received The researcher noted, it was difficult sometimes for some of the women to recall the information received during previous antenatal health sessions. This is because some of the women were unable to answer basic questions they were asked. The survey showed that though majority of the respondents’ said they could recall antenatal health information received, 30 respondents’ admitted that they easily forget health information they receive. As indicated in Table 2.4, 26.1 percent of the respondents’ easily forgot antenatal health information received while 73.9 percent did not forget health information received. University of Ghana http://ugspace.ug.edu.gh 4 6 Table 2.4. Respondents ’ who easily forgot antenatal health information Response Frequency Percentage YES 30 26.1 NO 85 73.9 TOTAL 115 100.0 Below in figure 1.8 is a bar graph that shows the frequency of woman who easily forgot antenatal health information they received. Fig. 1.8. The survey also showed that more than half of the respondents’ said that it was sometimes difficult to understand antenatal health information they received. In Table 2.5, 65 respondents’ had difficulty in understanding the antenatal health information they received sometimes while 50 respondents’ said they did not have difficulty in understanding antenatal health information. University of Ghana http://ugspace.ug.edu.gh 4 7 Table 2.5. Respondents ’ who sometimes had difficulty in understanding antenatal health information Response Frequency Percentage YES 65 56.5 NO 50 43.5 TOTAL 115 100.0 5.0 . Respondents ’ ability to work with health information The survey revealed that antenatal health information received and instructions given were generally used and followed by pregnant women. Table 2.6 indicates that almost 94.8 percent of respondents’ used antenatal health information they received and followed the instructions given them while 5.2 percent did not. Table 2.6. Respondents’ ability to follow instructions and work with health information received Response Frequency Percentage YES 109 94.8 NO 6 5.2 TOTAL 115 100.0 This therefore could imply that despite the difficulty for women to sometimes understand antenatal health information, they generally used the health information they received and followed instructions in their own interest. University of Ghana http://ugspace.ug.edu.gh 4 8 5.1 . Challenges in Antenatal Health Information dissemination Despite consistent efforts to sustain and better the dissemination of antenatal health information at Tema Polyclinic, a number of challenges were identified by key staff of the Polyclinic. The in-depth interviews revealed that the high number of women who attend antenatal care sessions makes it difficult to assess whether or not the antenatal health information shared was well received. It was also stated that much has not been done to assess antenatal health communication to the extent of finding out how well they (Tema Polyclinic) have done. Language barrier was also mentioned as one of the challenges in sharing antenatal health information. The antenatal health nurse indicated that: ³«say you are Ewe and the midwife is Fante, and you don’t understand English so we need to get a third party. Mostly antenatal is about confidentiality so even if you involve the other colleagues they don’t feel comfortable so it is difficult to get proper feedback .´ It was also mentioned during the in-depth interview that the women sometimes give wrong contact numbers and in instances where they have to follow-up by phone call, it becomes impossible to reach them. Apart from this, some women are unable to attend the antenatal health education sessions because they do not have the financial means to pay for their transportation. Additionally, it was indicated that some women were not patient enough to wait for their turn during the focused antenatal or one-on-one sessions. This is because they were in a hurry to leave the clinic and probably attend to something else so when clients before them delayed, they complained and sometimes walk out. It was also noted that some of the pregnant were truants and made their work difficult. University of Ghana http://ugspace.ug.edu.gh 4 9 Furthermore, it was revealed during the in-depth interviews that inadequate models and artefacts were a challenge particularly when the discussion during antenatal health education session require demonstration. Despite these challenges, it was emphasized during the in-depth interviews that antenatal health information dissemination has seen some improvement especially with the introduction of new methods like focused antenatal care. University of Ghana http://ugspace.ug.edu.gh 5 0 CHAPTER FIVE DISCUSSION OF FINDINGS, CONCLUSION AND RECOMMENDATIONS 5.0. Introduction The study was undertaken to find out how antenatal health information is disseminated at Tema Polyclinic. This chapter discusses the findings of the study in the previous chapter. The findings were discussed in the light of related studies on antenatal health communication, the objectives of the study and the research questions. The discussion forms the basis for the conclusions drawn and the recommendations made for the study. 5.1 . Antenatal Health Communication Firstly, in response to the channels and materials used in disseminating antenatal health information at Tema Polyclinic, the study revealed that the face-to-face channels was generally used. Channels like video and mobile phones were least used in disseminating antenatal health information. 7he survey showed that . percent of the respondents’ said videos were not used to share antenatal health information and 87 percent also admitted that mobile phones were not used as channels of communication. 6imilarly the study conducted by '’Ambruoso et al  in Accra indicated that one of the components of care that stood out, which is also the expectation of women before and during delivery was how individual health care providers cared and related to them on one-on-one basis. University of Ghana http://ugspace.ug.edu.gh 5 1 It was also indicated that some communication materials are used to aid and enhance the dissemination of antenatal health information at the Tema Polyclinic. Examples of these communication materials were posters, leaflets and booklets, and models. The survey showed that . percent of the respondents’ acknowledged that posters were used for illustration during antenatal health education. Also, 68 percent of the respondents’ said that leaflets and booklets were used to share health information. The use of models for demonstration was admitted by 51 percent of the respondents’. Similarly, Sangaré et al (2012) found out in a study they conducted that posters of insecticide treated nets were likely to have influenced some women who slept under the nets rather than receiving the nets for free. This outcome emphasizes the impact of communication materials as a means of enhancing and aiding antenatal health information dissemination. Secondly, concerning the forms of communication used in disseminating antenatal health information, the study revealed that group and one-on-one communication are the two main forms of communication used. The one-on-one communication is referred to as focused antenatal. Even though both forms of communication are used, the survey indicated that majority of the respondents’ preferred one-on-one form of communication to the group. Only  respondents’ preferred the group form of communication while  respondents’ preferred the one-on-one. Additionally, the study revealed that the Polyclinic had an exclusive group antenatal health session once a quarter called Daddy’s clinic which is a directive of the Ghana +ealth 6ervice aimed at involving husbands in pregnancy and delivery. University of Ghana http://ugspace.ug.edu.gh 5 2 Thirdly, concerning the languages used in disseminating antenatal health information, the study revealed that even though English language was generally used, the survey showed that majority of the respondents’ preferred the use of the local language. As many as 100 respondents’ said they preferred the use of local language to (nglish when antenatal health information is shared with them. Only 15 respondents’ said they preferred English language to be used in disseminating antenatal health information. The survey also showed that despite the high preference for local language use, 80.9 percent of the respondents’ were indifferent about the language used in disseminating antenatal health information. Also, the researcher observed that sign language was used to disseminate antenatal health information to a hearing impaired pregnant woman by her husband during antenatal health education sessions. Apart from this the study revealed that the antenatal care unit at the Tema Polyclinic finds out the ability of women to read, write and understand the English language. This informs antenatal care unit about the literacy levels of women and helps them to use the appropriate language and means in sharing health information. The survey showed that 80 percent of the respondents’ were able to read, write and understand English while 20 percent were not able to do so. A similar study by Tsianakas and Liamputtong (2002) indicated that the cultural backgrounds of pregnant women and the issue of language are critical in disseminating antenatal health information. University of Ghana http://ugspace.ug.edu.gh 5 3 Furthermore, women were given opportunity to ask questions on issues bothering them. This was made a key part of antenatal health information dissemination at Tema Polyclinic as it gives the antenatal care unit feedback and helps them to clarify misunderstandings on the minds of the pregnant women. 7he survey showed that majority of the respondents’ admitted that they were able to freely ask questions on their mind when they are alone with the doctor or nurse. As many as 109 respondents said they were able to freely ask the doctor or nurse questions when alone with them. On the contrary, almost half of the respondents numbering 54 expressed difficulty in freely asking the doctor or nurse questions during group sessions. Also, 107 respondents acknowledged that they had the freedom to ask the doctor or nurse questions. In a similar study conducted by Pell et al (2013), it was found that one of the factors that influenced women’s attendance of antenatal health care sessions had to do with the response they got in terms of communication. Additionally, women’s ability to understand, remember and follow the instructions given at antenatal health sessions is critical in determining the effectiveness of the health information disseminated. Even though the survey showed that 65 percent of women said it was sometimes difficult to understand antenatal health information, only 26 percent said they easily forgot the health information they received. On the contrary, a study by 1ikie’ma et al  revealed that majority of the women could not remember receiving information on difficulties during pregnancy. University of Ghana http://ugspace.ug.edu.gh 5 4 Also the survey indicated that a majority of . percent of the respondents’ at the 7ema Polyclinic admitted that they followed instructions and worked with the health information they received. Finally, the study indicated that high attendance of antenatal care sessions by pregnant women, language barrier, inadequate communication materials for demonstration and impatient and problematic pregnant women are basically the source of challenges faced by the antenatal care unit in disseminating antenatal health information. The in-depth interviews however revealed antenatal health information dissemination has improved at Tema Polyclinic despite the challenges. 5.2 . Conclusions The following conclusions were drawn from the findings, analysis and discussions of how antenatal health information is disseminated at Tema Polyclinic: In the first place, leaflets and booklets, models and artefacts, and posters were the satisfactorily used communication materials and channels in disseminating antenatal health information at Tema Polyclinic. This is because the survey indicated that . percent of respondents’ confirmed the use of leaflets and booklets, 51.3 percent confirmed the use of models and artefacts, and 60.9 percent confirmed the use of posters in disseminating antenatal health information. University of Ghana http://ugspace.ug.edu.gh 5 5 Secondly, both group and one-on-one forms of communication are equally used at Tema Polyclinic during antenatal health care sessions. This was revealed during the in-depth interviews and also observed by the researcher. Focused antenatal or one-on-one sessions were preferred to group antenatal health sessions. This was confirmed by 76.5 percent of the respondents’ in the survey. Thirdly, majority of the pregnant women utilizing antenatal health care at Tema Polyclinic prefer the use of the local language in antenatal health information dissemination. The survey revealed that 87 percent of respondents’ confirmed their preference for the use of the local language to English during antenatal health education. Fourthly, most women utilizing antenatal health care at Tema Polyclinic work with the antenatal health information they received. Again, the survey showed that 94.8 percent of the respondents’ confirmed that they followed instructions and worked with health information received. Finally, the high population of pregnant women who access the antenatal care unit at the Tema Polyclinic, inadequate communication material for demonstration, language barrier and grim conduct of some pregnant women were the main challenges of antenatal health information dissemination. These challenges were revealed during the in-depth interviews. University of Ghana http://ugspace.ug.edu.gh 5 6 5.4. Recommendations The conclusions drawn from this study led to the following recommendations which could be helpful to further improve antenatal health information dissemination at the Polyclinic: 1. Firstly, in view of the fact that there may be some pregnant women who are unable to read and understand the English language, there is the need for a deliberate effort to identify pregnant women who fall in that category to benefit from a tailor-made antenatal education session. 2. Secondly, it will also be helpful if other channels that were least used are explored to disseminate antenatal health information. For example recording basic antenatal health information on a step by step basis in different languages on digital video discs '9'’s and make them available to pregnant women so that they can listen to and watch the recorded information. The use of mobile phone could also be explored further. 3. Thirdly, considering the preference for the use of local language in disseminating antenatal health information, it will be helpful to train antenatal health providers to be able to disseminate health information effectively in the local languages so as to increase the use of local languages for that purpose. 4. Fourthly, it will be helpful to allot a lot more time for one-on-one antenatal health education to allow for the pregnant women to freely share their concerns. 5. Also, it will be helpful if the a call-centre is set up to attend to pregnant women in terms of responding to questions and providing other helpful information instead of having to be present at the Polyclinic physically. 6. Finally, it will also be helpful if Tema Polyclinic makes provision for the hearing impaired by engaging the services of specialist sign language communicators. University of Ghana http://ugspace.ug.edu.gh 5 7 5.5. Limitations of the Study The first limitation of this study is with the sample size. This limitation was due to inadequate time factor, logistical and resource constraints. Also, because this is a case study, the results are indicative rather than generalized. Secondly, the trustworthiness of the responses from the respondents’ who took part in the survey cannot be fully assured. Thirdly, some of the pregnant women because of their condition declined their participation in completing the questionnaire. University of Ghana http://ugspace.ug.edu.gh 5 8 BIBLIOGRAPHY Anya, S. E., Hydara, A., & Jaiteh, L. E. (2008). Antenatal care in The Gambia: missed opportunity for information, education and communication. BMC pregnancy and childbirth, 8(1), pp 9. %ansah 0. 2’%rien %. Oware-Gyekye, F. (2009). Perceived prenatal learning needs of multigravid Ghanaian women. Midwifery, 25(3), pp. 317-326 Banta, D. (2003). What is antenatal (or preinstall) care? What are its boundaries? 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Retrieved June 15, 2013 from http://www.who.int/healthinfo/statistics/indantenatal/en/ Yin, R. K. (1994). Case Study Research: Design and Methods. Thousand Oaks, CA: Sage Publications. Yin, R. K. (2003). Case study research design and methods third edition. Applied social research methods series, Vol 5. Sage Publications. University of Ghana http://ugspace.ug.edu.gh 6 4 APPENDIX QUESTION GUIDE 1. How does antenatal health care begin at Tema Polyclinic? 2. What are the channels used in disseminating antenatal health information? 3. Which communication materials are used in antenatal health education?  Are the communication materials easy to read and understand?  Are the communication materials relevant to address peculiar individual pregnancy needs? 4. What type or kind of communication is used in disseminating antenatal health information?  At what stage of the antenatal health information dissemination process do you use group communication?  At what stage of the antenatal health information dissemination process do you use one-on-one communication? 5. What language is normally used in disseminating antenatal health information and why? 6. How do you assess antenatal health information dissemination in Tema Polyclinic? 7. What are the challenges encountered in disseminating antenatal health information at Tema Polyclinic? University of Ghana http://ugspace.ug.edu.gh 6 5 APPENDIX QUESTIONNAIRE Dear Respondent, This survey seeks to find out how antenatal health information is disseminated at Tema Polyclinic. Kindly evaluate the following statements by ticking YES or NO. Please note that the results of this questionnaire will be used for academic purposes. Also antenatal health care in this questionnaire is referred to as ANC. Thank you. 1 I am able to read, write and understand English YES NO 2 I am able to read, write and understand my local language YES NO 3 The doctor or ANC nurse uses posters with illustration to inform me about antenatal health YES NO 4 The doctor or ANC nurse gives me leaflets to inform me about antenatal health YES NO 5 The doctor or ANC nurse uses models to inform me about antenatal health YES NO 6 The doctor or ANC nurse sends me antenatal health information on my mobile phone sometimes YES NO 7 Videos are shown to inform me about antenatal health YES NO 8 I prefer the doctor or ANC nurse to use English language to inform me about antenatal health YES NO 9 I prefer the doctor or ANC nurse to use my local language to inform me about antenatal health YES NO 10 , don’t mind the language used to inform me about antenatal health as long as I understand YES NO 11 It is sometimes difficult to understand the information I receive during antenatal health sessions YES NO 12 I am free to ask the doctor or ANC nurse any question bothering me about antenatal health YES NO University of Ghana http://ugspace.ug.edu.gh 6 6 13 I easily forget the information I receive during antenatal health sessions YES NO 14 I am able to ask for more questions about antenatal health when I am alone with the doctor or ANC nurse YES NO 15 I find it difficult to ask questions during group ANC sessions YES NO 16 I prefer to be with the doctor or ANC nurse alone than to be in a group for ANC sessions YES NO 17 I try to follow and abide by the information I receive during ANC sessions YES NO 18 I am below 30 years of age YES NO University of Ghana http://ugspace.ug.edu.gh