Ready to deliver maternal and newborn care? Health providers’ perceptions of their work context in rural Mozambique

Figures & data

Figure 1. Study setting displaying included districts and health facilities, in Maputo and Gaza provinces, Mozambique.

Table 1. Definitions of COACH dimensions.

Dimension Sub-dimensions	Definition*
Organizational resources Human resources, Space, Communication and transport, Medicines and equipment, Financing	The availability of resources that allow an organization (unit) to adapt successfully to internal and external pressures
Community engagement	The mutual communication, deliberation and activities that occur between community members and an organization (unit)
Monitoring services for action	The process of using locally derived data to assess performance and plan how to improve outcomes in an organization (unit)
Sources of knowledge	The availability and use of sources of knowledge in an organization (unit) to facilitate best practice
Commitment to work	The individual’s identification with and involvement in a particular organization (unit)
Work culture Culture of learning and change, Culture of responsibility	The way ‘we do things’ in an organization (unit) reflecting a supportive work culture
Leadership	The actions of a formal leader in an organization (unit) to influence change and excellence in practice achieved through clarity and engagement
Informal payment Informal payment, Nepotism, Accountability	Payments or benefits given to individual(s) in an organization (unit), which are made outside the officially accepted arrangements, to acquire an advantage or service

*Unit refers to the department or primary health care centre where the respondent is working.

Table 2. Analysis framework for the COACH tool response process in Mozambique.

Five types of problems in Conrad and Blair’s taxonomy
Lexical problems	difficulties in understanding the meaning of a word or a phrase
Inclusion/exclusion problems	difficulties in determining what to include or exclude in a word used in an item
Temporal problems	difficulties in responding to an item if the scale does not fit
Logical problems	when the item has more than one focus or includes, for example, negations or contradictions
Computational problems	residual types of problems
Magnitude of the problem’s effect on response data
Prominent problems	when the participants did not understand the content of the item or had insufficient information to answer the item
Minor problems	when the participants had to reread the content of the item several times and/or asked for help from interviewers but managed to provide a grounded response

Table 3. Demographic characteristics of the respondents (n = 175) in Maputo and Gaza provinces, 2016.

Respondents characteristics	N = 175
Age (years)	Median	IQR*
	31	28–38.5
Gender	Frequency	Percent
Female	141	80.6%
Male	34	19.4%
Professional category	Frequency	Percent
Physician	5	2.8%
Surgeon Officer	4	2.3%
Medical Officer	12	6.9%
Nurse/midwife	115	65.7%
Auxiliaries	39	22.3%
Respondents by healthcare levels	Frequency	Percent
Level I	108	61.7%
Level II	57	32.6%
Level III	10	5.7%
Respondents by districts	Frequency	Percent
Bilene	27	15.4%
Chibuto	25	14.3%
Magude	19	10.9%
Chokwe	19	10.9%
Manhiça	51	29.1%
Xai-Xai	34	19.4%
Years working in the current facility	Median	IQR
	3	1–7

*IQR = Inter Quartile Range

Table 4. Internal consistency of the COACH tool in Mozambique, 2016.

Dimension	No items	Score range	α^a
Organizational resources	11	1–5	.80
Community engagement	5	1–5	.82
Monitoring services for action	5	1–5	.82
Sources of knowledge	5	0–1	.64
Sources of knowledge, items 24–26 removed	2	0–1	.74
Commitment to work	3	1–5	.82
Work culture	6	1–5	.73
Leadership	6	1–5	.91
Informal payment	8	1–5	.68
Informal payment, item 45 removed	7	1–5	.70

^aCronbach Alpha coefficients

Table 5. Summary of context data for health workers individually and aggregated to district level using the COACH tool in Southern Mozambique, 2016.

				Districts mean (SD)
Dimensions of context Sub-dimensions	Number of items	Scale	Total Sample (n = 175) mean (SD)	Bilene	Chibuto	Magude	Chokwe	Manhiça	Xai-Xai	ANOVA p
Organizational Resources	11	1–5	3.2 (1.4)	3.0 (1.4)	3.2 (1.4)	3.2 (1.2)	3.0 (1.3)	3.3 (1.4)	3.4 (1.3)	0.171
Human resources	2	1–5	3.1 (1.2)	3.0 (1.1)	3.3 (1.0)	3.3 (1.1)	2.1 (1.2)	3.4 (1.2)	3.2 (1.2)	-
Space	1	1–5	2.7 (1.3)	2.4 (1.0)	1.8 (0.9)	2.7 (0.9)	3.0 (1.2)	2.9 (1.5)	3.1 (1.5)	-
Communication & transport	2	1–5	3.0 (1.6)	2.6 (1.6)	3.1 (1.6)	2.8 (1.5)	2.6 (1.3)	3.2 (1.6)	3.4 (1.6)	-
Medicines and equipment	4	1–5	3.9 (1.0)	3.9 (1.1)	4.1 (1.0)	3.7 (0.8)	3.7 (1.1)	4.0 (1.1)	4.1 (1.0)	-
Financing	2	1–5	2.4 (1.2)	2.0 (1.1)	2.1 (1.2)	2.6 (1.1)	2.8 (1.0)	2.2 (1.1)	2.7 (1.2)	-
Community engagement	5	1–5	4.3 (1.2)	4.5 (0.6)	4.4 (0.6)	4.3 (0.7)	4.1 (0.7)	4.3 (0.8)	4.3 (0.9)	0.263
Monitoring services for action	5	1–5	4.2 (0.7)	4.2 (0.8)	4.4 (0.6)	4.0 (0.7)	4.2 (0.7)	4.3 (0.7)	4.2 (0.7)	0.428
Sources of knowledge	2	0–1	0.7 (0.4)	0.7 (0.4)	0.7 (0.4)	0.7 (0.4)	0.9 (0.3)	0.7 (0.4)	0.6 (0.4)	0.141
Commitment to work	3	1–5	4.4 (0.1)	4.6 (0.7)	4.4 (0.8)	4.0 (1.0)	4.0 (0.9)	4.4 (0.9)	4.5 (0.5)	0.453
Work culture	6	1–5	4.4 (0.7)	4.4 (0.8)	4.5 (0.6)	4.2 (0.7)	4.1 (0.8)	4.5 (0.7)	4.4 (0.7)	0.004*
Culture of learning and change	3	1–5	4.3 (0.7)	4.2 (1.0)	4.3 (0.7)	4.1 (0.7)	4.1 (0.7)	4.4 (0.8)	4.4 (0.6)	-
Culture of responsibility	3	1–5	4.5 (0.7)	4.7 (0.6)	4.7 (0.5)	4.2 (0.7)	4.1 (0.8)	4.6 (0.7)	4.5 (0.7)	-
Leadership	6	1–5	4.2 (0.8)	4.3 (0.7)	4.1 (0.6)	3.8 (0.8)	4.0 (0.7)	4.1 (1.0)	4.4 (0.6)	0.035*
Informal Payment	7	1–5	4.5 (1.0)	4.7 (0.7)	4.7 (0.7)	4.4 (1.0)	4.2 (1.0)	4.4 (1.2)	4.5 (1.0)	0.007*
Informal payment^a	3	1–5	4.7 (0.7)	4.9 (0.4)	4.9 (0.4)	4.6 (0.7)	4.4 (1.1)	4.8 (0.8)	4.7 (0.8)	-
Nepotism^a	2	1–5	4.3 (1.0)	4.5 (0.9)	4.5 (1.0)	4.4 (1.0)	4.0 (1.2)	4.2 (1.0)	4.1 (1.1)	-
Accountability	2	1–5	4.3 (1.2)	4.7 (0.8)	4.7 (0.5)	4.0 (1.3)	4.3 (0.6)	3.9 (1.6)	4.5 (1.0)	-

^aReversed scores were used for negatively worded items

Table A1. Type and magnitude of problems identified for items of the COACH tool in Mozambique and decisions made, 2016.

Dimension/item	Type and magnitude of problems	Decision
Organizational resources
1. My unit has enough workers with the right training and skills to do everything that needs to be done. PROBLEM: The item contains two elements – enough staff AND having the right training and skills. Respondent unsure how to rate agreement if, e.g. there are not enough staff but the staff available have adequate training and skills?	Logical, prominent	Explain to the respondent that both elements of the item must be fulfilled to agree that the resource is available.
4. My unit has access to the transport and fuel that are needed to provide healthcare services. PROBLEM: The item contains two elements – transport AND fuel. Respondent unsure how to rate agreement if, e.g. a vehicle is available but fuel is not?	Logical, prominent	Explain to the respondent that both elements of the item must be fulfilled to agree that the resource is available.
7. My unit has enough functional equipment, such as a thermometer and blood pressure cuff, to provide healthcare services. PROBLEM: The examples provided in the item (i.e. thermometer and blood pressure cuff) could be perceived by a respondent as the only equipment that is requested.	Inclusion/Exclusion, minor	Give more examples of equipment and clarify in the instructions that the examples should not limit the scope of the different equipment and that the respondent should ask for clarification if not sure about the mean of the examples.
9. If the workload increases, my unit can get additional resources such as medicine and equipment. PROBLEM: does the statement mean that the additional resources needed, in case of increased workload, must be immediately available?	Lexical, minor	Explain to the respondent that the meaning is whether there is a system to ensure the resources needed are made available ASAP.
Community engagement
NO Problems
Monitoring services for action
21. My unit regularly compares its work with national or other guidelines. PROBLEM: ‘National guidelines’ was translated to ‘normas nacionais’, which was not clearly understood by a respondent.	Lexical, minor	Provide the other synonyms for ‘guidelines’ in Portuguese, e.g. guias, protocolos”.
Sources of knowledge
No Problems
Commitment to work
No Problems
Work culture
30. My unit is willing to use new healthcare practices such as the guidelines and recommendations. PROBLEM: The respondent didn’t understand the meaning of ‘willing to use’ in the item. Does it mean that the unit wants to use new healthcare practices or it is planning to use them?	Lexical, minor	Explain that the concept in this item is the ‘openness to change’.
33. My unit works for the good of the clients and puts their needs first. PROBLEM: The item contains two topics – the good of the clients AND taking the clients’ needs first…	Logical, minor	Explain that taking the clients’ needs first implies somehow the client’s wellbeing.
Leadership
38. The leader actively listens, acknowledges, and then responds to requests and concerns. PROBLEM: the item contains three actions that the leader is supposed to do – listening, acknowledging and responding to requests and concerns. How should we answer the item if the leader completes one action and not one or two of the others?	Logical, minor	Explain that all three concepts in the item must be fulfilled to answer positively.
39. The leader effectively resolves any conflict that arises. PROBLEM: what is meant by ‘effectively resolves’: to resolve in a just way? Or in an appropriate way?	Lexical, minor	Translate in a meaningful way the idea of ‘effectively resolve’ in Portuguese, in the sense that conflicts are managed in a manner aimed at achieving the desired result.
Informal payments
45. Health workers are sometimes absent from work earning money at other places. PROBLEM: This is a sensitive question. The statement as it is translated in Portuguese, can be perceived as offensive because most of the health workers in Mozambique have to work in other places because the salary they earn is not enough for their basic needs. Could it be said instead that ‘Sometimes health workers are absent because they have to work in other places’?	Lexical, minor	Find a meaningful way to say ‘earn money’ in Portuguese, according to the actual context, where the health worker’s salary is not enough to meet their basic needs.
48. Efforts are made to stop clients from providing informal payments to obtain appropriate healthcare services. PROBLEM: The Portuguese translation is not clear in terms of who is making these efforts.	Lexical, minor	Clarify in the Portuguese version that the efforts mentioned in the sentence are intended to be completed by the health unit staff.

Table A2. Descriptive values of items and dimensions of the COACH tool in Mozambique, 2016.

				Number of ‘disagree’ answers		Number of ‘neutral’ answers		Number of ‘agree’ answers		Total number of respondents
Scaled Dimensions/Items	Range	Mean	Median score	n	%	n	%	n	%	N
Organizational Resources	1–5	3.2	4	-	-	-	-	-	-	175
Human resources	1–5	3.2	4	-	-	-	-	-	-
1. My unit has enough workers with the right training and skills to do everything that needs to be done	1–5	2.8	2	96	54.9%	16	9.1%	63	36.0%	175
2. My unit has enough workers with the adequate training and skills to do their job in the best possible way	1–5	3.5	4	46	26.3%	13	7.4%	116	66.3%	175
Space	1–5	2.7	2	-	-	-	-	-	-
3. My unit has enough space to provide healthcare services	1–5	2.7	2	101	57.7%	13	7.4%	61	34.9%	175
Communication & transport	1–5	3.0	4	-	-	-	-	-	-
4. My unit has access to the transport and fuel that are needed to provide healthcare services	1–5	2.6	2	96	54.9%	15	8.6%	64	36.6%	175
5. My unit has access to communication tools (e.g. telephones or radios) that are needed to provide healthcare services	1–5	3.4	4	54	30.9%	8	4.6%	113	64.6%	175
Medicines and equipment	1–5	3.9	4	-	-	-	-	-	-
6. My unit has enough medicine to provide healthcare services	1–5	4.1	4	18	10.3%	4	2.3%	153	87.4%	175
7. My unit has enough functional equipment, such a thermometer and blood pressure cuff, to provide healthcare services	1–5	4.0	4	27	15.4%	3	1.7%	145	82.9%	175
8. My unit has enough disposable medical equipment, such as syringes, gloves and needles, to provide healthcare services	1–5	4.2	4	19	10.9%	0	0.0%	156	89.1%	175
9. If the workload increases, my unit can get additional resources such as medicine and equipment	1–5	3.4	4	41	23.4%	31	17.7%	103	58.9%	175
Financing	1–5	2.4	3	-	-	-	-	-	-
10. My unit receives money according to an established financial plan	1–5	2.6	3	73	41.7%	75	42.9%	27	15.4%	175
11. My unit has money that we can decide how to use	1–5	2.1	2	98	56.0%	57	32.6%	20	11.4%	175
Community engagement	1–5	4.3	4	-	-	-	-	-	-
12. In my unit we ask community members what they think about the healthcare services that we provide	1–5	4.3	4	5	2.9%	10	5.7%	160	91.4%	175
13. In my unit we listen to what community members think about the healthcare services we provide	1–5	4.4	4	2	1.1%	8	4.6%	165	94.3%	175
14. In my unit we have meetings with community members to discuss health matters	1–5	4.5	5	3	1.7%	9	5.1%	165	93.2%	177
15. In my unit we encourage community members to contribute to improving the health of the community	1–5	4.5	5	5	2.9%	5	2.9%	165	94.3%	175
16. In my unit we encourage other organizations to contribute to improving the health of the community	1–5	4.0	4	10	5.7%	19	10.9%	146	83.4%	175
Monitoring services for action	1–5	4.2	4	-		-		-
17. I receive regular updates about my unit’s performance based on information/data collected from our unit	1–5	4.1	4	9	5.1%	17	9.7%	149	85.1%	175
18. My unit discusses information/data from our unit in a regular, formal way, such as in regularly scheduled meetings	1–5	4.4	5	3	1.7%	8	4.6%	164	93.7%	175
19. My unit regularly uses unit information/data to make plans for improving its healthcare services	1–5	4.2	4	4	2.3%	13	7.4%	158	90.3%	175
20. My unit regularly monitors its work by comparing it with the unit’s action plans	1–5	4.2	4	6	3.4%	17	9.7%	152	86.9%	175
21. My unit regularly compares its work with national or other guidelines	1–5	4.2	4	2	1.1%	17	9.7%	156	89.1%	175
Commitment to work	1–5	4.4	5	-		-		-
27. I am proud to work in this unit	1–5	4.4	5	7	4.0%	3	1.7%	165	94.3%	175
28. I am satisfied to work in this unit	1–5	4.3	4	9	5.1%	8	4.6%	158	90.3%	175
29. I feel encouraged to do my very best at work	1–5	4.4	5	10	5.7%	6	3.4%	159	90.9%	175
Work culture	1–5	4.4	5	-		-		-
Culture of learning and change	1–5	4.3	4	-	-	-	-	-	-
30. My unit is willing to use new healthcare practices such as guidelines and recommendations	1–5	4.3	4	4	2.3%	12	6.9%	159	90.9%	175
31. My unit helps me to improve and develop my skills	1–5	4.1	4	13	7.4%	13	7.4%	149	85.1%	175
32. I am encouraged to seek new information on healthcare practices	1–5	4.5	5	2	1.1%	7	4.0%	166	94.9%	175
Culture of responsibility	1–5	4.5	5	-	-	-	-	-	-
33. My unit works for the good of the clients and put their needs first	1–5	4.5	5	6	3.4%	6	3.4%	163	93.1%	175
34. Members of the unit feel personally responsible for improving healthcare services	1–5	4.5	5	2	1.1%	11	6.3%	162	92.6%	175
35. Members of the unit approach clients with respect	1–5	4.5	5	1	0.6%	9	5.1%	165	94.3%	175
Leadership	1–5	4.2	4	-		-		-
36. I trust the unit leader	1–5	4.2	4	5	2.9%	11	6.3%	159	90.9%	175
37. The leader handles stressful situations calmly	1–5	4.2	4	8	4.6%	18	10.3%	149	85.1%	175
38. The leader actively listens, acknowledges and then responds to requests and concerns	1–5	4.1	4	7	4.0%	16	9.1%	152	86.9%	175
39. The leader effectively resolves any conflicts that arise	1–5	4.0	4	10	5.7%	23	13.1%	142	81.1%	175
40. The leader encourages the introduction of new ideas and practices	1–5	4.3	4	5	2.9%	12	6.9%	158	90.3%	175
41. The leader makes things happen	1–5	4.1	4	10	5.7%	24	13.7%	141	80.6%	175
Informal Payment	1–5	4.5	5	-		-		-
Informal payment	1–5	4.8	5	-	-	-	-	-	-
42. Clients must always give informal payment to health workers to access healthcare services	1–5	4.7	5	162	92.6%	4	2.3%	9	5.1%	175
43. Clients are treated more quickly if they make informal payments to health workers	1–5	4.8	5	165	94.3%	7	4.0%	3	1.7%	175
44. Medicines or equipment that should be available for free to clients have been sold in my unit	1–5	4.8	5	167	95.4%	4	2.3%	4	2.3%	175
Nepotism	1–5	4.3	5	-	-	-	-	-	-
46. Health workers in my unit give healthcare services to friends and family first	1–5	4.3	5	137	78.3%	26	14.9%	12	6.9%	175
47. Health workers in my unit give jobs or other benefits to friends and family first	1–5	4.2	5	126	72.0%	30	17.1%	19	10.9%	175
Accountability	1–5	4.3	5	-	-	-	-	-	-
48. Efforts are made to stop clients from providing informal payment to get appropriate healthcare services	1–5	4.3	5	20	11.4%	5	2.9%	150	85.7%	175
49. Efforts are made to stop health workers from asking clients for informal payment	1–5	4.3	5	17	9.7%	8	4.6%	150	85.7%	175
				Number of ‘not available’, ’never’ and ’rarely’ answers		Number of ‘occasionally’ answers		Number of ‘frequently’ and ‘always’ answers		Total number ofrespondents
Non-scaled dimension/Items	Range	Mean	Median score	n	%	n	%	n	%	N
Sources of knowledge	0–5	0.7	2	-	-	-	-	-	-	175
22. Clinical practice guidelines	0–1	0.7	1	45	25.7%	29	16.6%	101	57.7%	175
23. Other printed material for work	0–1	0.7	1	35	20.0%	32	18.3%	108	61.7%	175
(a) Scaled items:	1-Strongly disagree, 2-Disagree, 3-Neither disagree, nor agree, 4-Agree, 5-Strongly agree.
	Scores of the dimensions were calculated using individual mean scores
(b) Non-scaled items:	0 (not available, never and rarely), 0.5 (occasionally), 1 (frequently and almost always)
	Scores of this dimensions was calculated as total sum of items
(c) Recoded into three categories	Disagree: (Strongly disagree and disagree)
	Neutral: (Neither disagree, nor agree)
	Agree: (Agree and strongly agree)