Lessons From a Behavior Change Intervention to Improve Provider-Parent Partnerships and Care for Hospitalized Newborns and Young Children in Kenya

"Research shows respectful, responsive care is associated with improved newborn and young child health outcomes, provider and parent satisfaction, and a decrease in the number of days in hospital and costs... and suggests integrability of nurturing and developmental care with child protection and parenting support interventions..."



The first 1,000 days (from pregnancy to 24 months) is the foundation of lifelong learning and development. This study sought to evaluate a provider behaviour change (PBC) intervention implemented by the Population Council in 5 hospitals in Nairobi and Bungoma counties, Kenya, in collaboration with the Kenya Ministry of Health (MOH) and its effect on: provider knowledge and practice related to respectful, responsive care; teamwork/peer support; communication between providers and parents; and parents' capacity to engage in the care of their newborn or young child while in the hospital.



After a formative study conducted in 2019, the research team engaged in a participatory cocreation process to draft a theory of change and develop and implement the intervention. The hybrid virtual and in-person cocreation process (early February 2020) involved parents of recently hospitalised newborns and young children (aged 0-24 months), healthcare providers in the 5 study hospitals, MOH policymakers, and other newborn and child health stakeholders in Kenya. The implementation approach emphasised aspects of the Research and Learning Agenda for Advancing Provider Behavior Change Programming developed by Breakthrough RESEARCH, which focuses on addressing norms and conditions that shape provider behaviours and parent experience. The multifaceted intervention included a 7-module orientation, feedback meetings, job aids, and psychosocial support - leveraging in-person and remote modalities - that focused on (i) provision of high-quality respectful care, interpersonal communication, and interactions with parents, including fathers and (ii) facilitation of better parent-provider engagement through increased awareness and coaching around essential integrative care elements and early childhood physical and cognitive development. Each facility displayed job aids, including adapted wall charts and protocols for young childcare, a provider-parent communication charter, and targeted messaging and posters on how fathers can participate. Videos (e.g., on helping a breastfeeding mothers) were also shared via WhatsApp by programme staff.

The researchers used a mixed-methods evaluation drawing on a pre-post provider survey, pre-post qualitative interviews with providers and parents, and a follow-up parental survey. Selected findings:

• There were significant post-intervention improvements in provider knowledge on safeguarding sleep, positioning and handling, and protecting skin. However, there were also significant reductions in providers' knowledge in identifying a child's pain, parental stress, and environmental stress. Furthermore, despite the provider training, qualitative data show that provider practices around managing pain and distress among hospitalised young children during the intervention period remained constrained. There is potentially some normalisation of pain in hospitalised young children in Kenya or at least insufficient motivation to do something about it, even though nonpharmacological ways to reduce pain and stress were introduced (and reinforced with a short video accessible to all providers) and can be readily adopted by parents and providers.
• Pre- and post-intervention qualitative data showed improvement in provider behaviour and communication within provider-parent interactions. The majority of parents rated very high on issues such as being spoken to gently (4%), using nonverbal gestures (95%), being listened to carefully (92%), clearly explained care (95%), and feeling confident to ask questions (92%). Almost all parents (99%) reported that the nurses answered their questions clearly using simple language.
• Among parents who received coaching from providers, there were higher levels of interpersonal communication between parent and provider, parental empowerment, and improved ability to provide integrated, responsive care to their child. Overall, the more information parents received through higher levels of communication, the more they felt empowered and confident in caring for their hospitalised child.
• Many fathers had reported a pre-intervention desire to be more involved in their young child's care. There was some improvement at the endline in their engagement, particularly in settings where the hospital visiting hours were changed to accommodate when they were free to attend after work and enabled their inclusion.

Endline findings were shared through county and national newborn and child health technical working groups and a webinar led by Kenyatta National Hospital for over 150 clinicians, academicians, and members of professional organisations.



Selected implications of the study include:

• Focusing on provider behaviour in a low-resource setting illuminated the importance of understanding providers' working environments and fostering an acceptable context before introducing any change. The results from the 2019 formative study were disseminated at 2 validation meetings with newborn and child health stakeholders to validate the study findings and jointly develop/cocreate the study interventions. The shared understanding - providers' understanding of parents' needs and parents' understanding of providers' working environment - helped shape the behaviour change intervention.
• Providing a platform or model of care that everyone could relate to - with the young child at the centre - enhanced communication across the board. A mix of mentoring (virtual and in person), physical job aids, soft-copy tools (videos and checklists), and monthly reflective discussions on monitoring data and feedback allowed for provider flexibility in using them to both learn and support communication with parents.

In conclusion: "This approach can be used as an example for future studies and programs to embed a nurturing and integrative responsive care approach into similar settings in sub-Saharan Africa."