Research Articles Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a qualitative study in three districts of the Eastern Region of Ghana Jeanette R Nelson 1 , Lisa H Gren 2 , Ty T Dickerson 3 , L Scott Benson 4 , Stephen O Manortey 5 , Rebecca Ametepey 5 , Yvette E Avorgbedor 5 , Stephen C Alder 6 1 Center for Business Health and Prosperity; University of Utah, USA, 2 Family and Preventive Medicine; University of Utah, USA, 3 Paediatrics; Family and Preventive Medicine; University of Utah, USA, 4 Family and Preventive Medicine; Internal Medicine; University of Utah, USA, 5 Ensign Global College, Ghana, 6 Center for Business, Health and Prosperity; Family and Preventative Medicine; University of Utah, USA; Ensign Global College, Ghana Keywords: childbirth, skilled health personnel, Health Belief Model, Ghana https://doi.org/10.29392/001c.29883 Journal of Global Health Reports Vol. 5, 2021 Background Although maternal mortality has decreased substantially since the 1990s, it remains one of the top priorities in global health, as most deaths can be prevented if women have access to and utilise skilled health personnel for childbirth delivery. While efforts have been made to increase the supply and accessibility of services, the lack of maternal utilisation of skilled health delivery services is a contributing cause of death, particularly among mothers from rural areas. Methods We conducted interviews in December 2019 in the Eastern Region of Ghana, with 24 rural mothers who had given birth within the past two years, 12 women who had and 12 women who had not given birth utilising skilled health personnel. Results The main differences between women who did and did not use skilled health personnel for delivery were for Health Belief Model constructs of perceived risk, self-efficacy, and cues to action. Most women who delivered with skilled health personnel believed they were susceptible to complications during childbirth, reported high perceived self-efficacy to overcome barriers to deliver with skilled health personnel, and planned and prepared in advance to deliver with skilled health personnel. In contrast, women who did not deliver with skilled health personnel were less likely to believe in susceptibility to complications, reported low perceived self-efficacy to overcome barriers, and had not planned or prepared in advance for skilled health delivery. Conclusions There were substantial differences between rural mothers who did and did not deliver with skilled health personnel regarding perceived susceptibility to experience complications, self-efficacy to overcome barriers and cues to action to prepare for birth. Maternal mortality is a global health priority. An esti- mated 295,000 deaths occur annually due to causes related to pregnancy and childbirth.1 While substantial progress was made from the 1990s to 2015, with maternal deaths de- creasing 44% from 385 to 216 deaths per 100,000 live births, the world failed to meet the Millennial Development Goal (MDG) targets of reducing deaths by 75% by 2015.2 Large disparities exist between and across regions and countries, with 99% of maternal deaths occurring in developing coun- tries.2 The majority of maternal deaths are preventable if a woman has skilled care at and around the time of birth.3 As such, the World Health Organization recommends that all women receive care with skilled health personnel for child- birth.4,5 Developing countries’ efforts to increase births attended by skilled health personnel have aimed at reducing barriers to access by measures, such as increasing the provision of skilled health personnel and implementing low or no cost maternal health services.6,7 Despite these efforts, global maternal rates of births attended by skilled personnel re- main suboptimal, particularly in rural areas where only two-thirds of women utilise skilled health personnel for de- livery, considerably lower than urban rates of nearly 90%.8 New targets set for 2016-2030 with the United Nations Sustainable Development Goals (SDG) call for a global rate of fewer than 70 maternal deaths per 100,000 live births by Nelson JR, Gren LH, Dickerson TT, et al. Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a qualitative study in three districts of the Eastern Region of Ghana. Journal of Global Health Reports. 2021;5:e2021102. doi:10.29392/001c.29883 https://doi.org/10.29392/001c.29883 https://doi.org/10.29392/001c.29883 2030 (SDG 3.1).2 Emphasising the importance of women re- ceiving skilled delivery care in reducing maternal mortal- ity, SDG 3.1.2 measures the proportion of births attended by skilled health personnel.8 Lack of utilisation of health services among rural women has been a critical issue in maternal deaths,6,9 making in- creasing demand and utilisation for essential maternal health services one of the most significant challenges in global health today.6 Key to increasing rural uptake of skilled health personnel for delivery is understanding varia- tions in care-seeking behaviour and why some rural women uptake skilled health personnel for delivery while others do not, given they likely face similar barriers. GHANA CONTEXT Ghana currently has a maternal mortality rate of 310 deaths per 100,000 live births10 and, like many other developing countries, is presently not on track to meet the SDG of no more than 70 deaths per 100,000 live births by 2030.1,11 Ghana is a country that has taken significant measures to reduce barriers to maternal health services through the ex- pansion of health services to rural areas through the Com- munity-Based Health Planning and Services (CHPS) pro- gram, initiated in 1999,12 and by offering free enrollment in the National Health Insurance Scheme (NHIS) since 2008, which provides free coverage of maternal health services, including childbirth.13,14 While most rural women enrol in maternal health insurance coverage, and 97% attend ante- natal care visits, nearly one-third (31%) of women still do not utilise skilled health personnel for childbirth.15 RESEARCH NEEDED Research is limited in applying theoretical models to under- stand maternal behaviour to utilise skilled health personnel for childbirth. This study’s contribution is applying a theo- retical model to understand rural maternal behaviour bet- ter, detect differences between rural women who do and do not uptake skilled health personnel for delivery, and iden- tify targets for interventions to increase rural women’s util- isation of skilled health personnel delivery. HEALTH BELIEF MODEL The Health Belief Model (HBM) is one of the most widely used theoretical frameworks to understand and predict health behaviours. Social scientists initially developed HBM during the 1950s to understand why people failed to take up behaviours to detect or prevent diseases, such as screening tests.16 The HBM asserts that individual behaviour is based on 1) desire to either avoid or recover from an illness con- dition for which an individual believes they are susceptible, and 2) belief that taking a particular action will prevent or mitigate the situation.17 Whether an individual embraces a health behaviour is related to perceptions of whether ben- efits outweigh barriers to taking the necessary action, pro- viding barriers are not so powerful to prevent action.16,17 Core components of the HBM (see Figure 1) include per- ceptions of susceptibility and severity to an illness condi- tion, benefits and barriers to taking action, cues to action to set in motion the decision to act, and self-efficacy, which refers to an individual’s confidence to perform a behaviour successfully leading to an outcome.16 Additionally, the HBM assumes factors such as socioeconomic status and ed- ucational level can alter perceptions of susceptibility, sever- ity, benefits, and barriers, thereby indirectly influencing be- haviour.16 METHODS STUDY DESIGN We used a qualitative descriptive phenomenology approach to explore differences among rural women to uptake skilled delivery care. The descriptive process uses individual in- depth interviews to explore individual experiences, iden- tifying poorly understood aspects of practices related to a phenomenon of interest.18 The underlying worldview in this research is pragmatism since this philosophy uses a practical approach and allows for more than one perspec- tive of participants’ experiences.18 The HBM was employed as the theoretical framework to explore maternal behaviour differences since the HBM has been used extensively to un- derstand health behaviours better.16 The study was ap- proved by the Ethics Review Committee from Ensign Col- lege of Public Health in Ghana. Additionally, this qualitative study was planned to inform a quantitative study on the same topic. RESEARCH SETTING The research took place in the Eastern Region of Ghana, a primarily rural region, with nearly two-thirds of the popu- lation of 2,106,696 residing in rural areas.19 The primary in- dustry is agriculture, followed by wholesale or retail trade.19 The most common type of home is constructed of mud en- tailing one to two rooms.19 The Region is divided into 26 administrative districts. Three districts were selected to be included in our study based on proximity and accessibility to researchers: Lower Manya Krobo, Yilo Krobo, and Asuo- gyaman Districts. Six communities, two rural communities from each of the three districts, were purposively selected based on input from Municipal Health Directors. Interviews were conducted at participants’ homes in December 2019. Two female researchers and the participant were present during the interviews. Other individuals initially present were respectfully asked to allow privacy due to sensitive discussions on maternal health issues. STUDY POPULATION The target population was rural Ghanaian women aged 15 to 49 who had delivered a child in the past two years and are residents of the participatory community. Participants were purposively selected for in-depth face to face inter- views. Nurses at the CHPS, informed of the study in ad- vance, directed researchers to areas where women resided who had and had not delivered with skilled health person- Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 2 Figure 1. Constructs of the Health Belief Model. Modified from Glanz, Rimer and Viswanath (2015)16 nel. When no CHPS nurse was available, researchers asked older women in the community where women meeting the study criteria resided. Participation was high, with only two women declining to be interviewed due to prior commit- ments. DATA COLLECTION Data were collected through 24 individual in-depth single interviews, 12 mothers who did and 12 mothers who did not utilise skilled health personnel for delivery. Each face- to-face interview lasted approximately 45 minutes. The au- thors developed a semi-structured guide based on questions generated from a literature review. Women were asked to describe perceptions related to their most recent pregnancy and delivery experience with open-ended questions. The guide was field-tested and revised (JN, RA, YA) prior to data collection. The three female researchers (JN, RA, YA) were knowledgeable in reproductive health issues and had pre- vious training and experience in qualitative interview tech- niques and qualitative research procedures. The research purpose was explained to participants, and informed consent was obtained prior to interviews through a signature or thumbprint. Researchers had no preexisting relationship with participants. All interviews were con- ducted in the local languages (Krobo, Twi, or Ewe) predom- inantly spoken in the study area by one researcher (RA) to maintain interview quality and consistency, while a second researcher (JN) took field notes. Saturation was achieved, which was the point at which interviews did not reveal new themes or information. Interviews were audio-recorded and later translated into English by a researcher (RA), based on topic and question, capturing the essence of what par- ticipants said, translating representative quotes verbatim. A second researcher (JN) recorded responses. A third re- searcher (YA) independently listened to recordings and re- viewed transcripts to ensure accuracy. Where differences occurred, two researchers (RA, YA) discussed until reaching consensus. DATA ANALYSIS Data were analysed following data analysis and represen- tation for phenomenology research in Creswell & Poth.18 First, after researchers (JN, RA, YA) reviewed all responses, a researcher (JN) created data files, compiling participant responses, and field notes from each topic and question. Second, researchers (JN, RA, YA) read through texts several times, making notes and coding text lines broadly, then iteratively modifying as patterns emerged. Third, themes were generated within the context of the HBM framework common to both groups and differentiated women based on the utilisation of skilled delivery care. Fourth, explanatory quotes were highlighted, revealing insight into women’s in- dividual experiences and beliefs. Fifth, descriptions were developed that represented everyday, and differentiating experiences among women who did vs did not utilise skilled health personnel for delivery. Data were entered into Excel by one researcher (JN) and reviewed by two researchers (RA, YA). Results were reported following the guidance of the Standards for Reporting Qualitative Research (SRQR) checklist.20 Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 3 https://www.joghr.org/article/29883-using-the-health-belief-model-to-explore-rural-maternal-utilisation-of-skilled-health-personnel-for-childbirth-delivery-a-qualitative-study-in-three/attachment/75767.jpeg Table 1. Characteristics of rural Ghanaian mothers who gave birth in the previous two years, by utilisation of skilled health personnel for delivery Utilised skilled health personnel for delivery Total Yes No Characteristic N=24 n=12 n=12 Age (years): 16-19 6 4 2 20-29 12 6 6 30-36 6 2 4 Marital Status Married 16 7 9 Cohabitating 7 5 2 Single 1 0 1 Education level None 4 1 3 Primary 10 6 4 Middle/Junior High School 9 5 4 Senior High School 1 0 1 Occupation Farming 6 2 4 Trading 11 7 4 Hairdresser 3 2 1 Unemployed 4 1 3 Ethnicity (Tribe) Krobo 15 7 8 Ewe 6 2 4 Other 3 3 0 Religion Christian 24 12 12 Parity 1 to 2 9 5 4 3 to 4 10 6 4 5 to 6 5 1 4 RESULTS CHARACTERISTICS OF PARTICIPANTS The sample consisted of 24 participants, 12 women who utilised skilled health personnel for their last childbirth, and 12 who did not. Demographic characteristics are pre- sented in Table 1. Participants were aged 16-36 years (me- dian 25), and most were married or cohabitating. Most women had either a primary or middle school education and were employed in trading or farming. Parity ranged between 1-6 children (median: 3). Self-reported obstetric characteristics of participants are presented in Table 2. Nearly all women possessed health in- surance with their last pregnancy and attended antenatal visits. The number of four or more antenatal visits was se- lected based on the recent Ghana Maternal Health Survey.10 Almost half perceived that they had ever had a pregnancy or birth complication. The primary mode of transportation to the health facility was walking, and travel time ranged from under 30-minutes to considerably longer times of one to two hours. FINDINGS RELATED TO THE HEALTH BELIEF MODEL A summary of the main findings is provided in Table 3 and Figure 2. Based on the HBM framework, essential differ- ences emerged between women who did and did not utilise skilled delivery care in the following areas: perceived sus- ceptibility, perceived self-efficacy, and cues to action. Com- mon themes emerged among both groups of women of per- ceptions of benefits and barriers to skilled delivery care. Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 4 Table 2. Obstetric factors of rural Ghanaian mothers who gave birth in the previous two years, by utilisation of skilled health personnel for delivery Utilised skilled health personnel for delivery Total Yes No Characteristic N=24 n=12 n=12 Health insurance (during recent pregnancy) Yes 23 12 11 No 1 0 1 Previous pregnancy or birth complication (ever) Yes 11 9 2 No 13 3 10 Antenatal Visits none 1 0 1 1 to 3 4 1 3 4 or more 19 11 8 Time to Health Facility < 30 min. 14 6 8 30 min to < 1 hour 0 0 0 1 to 2 hours 9 6 3 more than 2 hours 1 0 1 Ever used modern contraception Yes 9 5 4 No 15 7 8 MODIFYING FACTORS KNOWLEDGE AND AWARENESS Women were asked questions about knowledge and aware- ness of recommended guidelines to uptake skilled health personnel for delivery, where to obtain maternal health ser- vices, and causes/prevention of maternal death. Most women, regardless of whether they delivered with skilled health personnel or not, were aware of recom- mended guidelines to deliver using skilled health person- nel, responding that Ghana Health Services recommends that 'you should go to the hospital or [health centre] and have a nurse or midwife deliver your baby. However, a cou- ple of women were not aware of the recommended guideline that all women should utilise skilled health personnel for delivery. Additionally, nearly all women knew where to ob- tain maternal health services. Women from both groups generally believed that maternal death could be caused by physical, behavioural, and spiritual factors. Perceived phys- ical causes include examples such as bleeding, disease, and difficult labour. Perceptions of maternal behavioural causes include examples such as lack of uptake of recommended antenatal healthcare visits and poor diet. Beliefs of spiritual causes include spells, curses, and evil ancestral spirits. Women generally believed measures to prevent maternal death included attending antenatal visits, proper nutrition, or spiritual practices. However, women thought skilled health personnel could do nothing to pre- vent or treat childbirth complications related to spiritual factors as only a religious leader such as the fetish priest or pastor might be able to intervene if discovered soon enough. There were no major differences observed between groups. “Disease, not eating good food or some people who hate people can cast a spell on a pregnant woman [to die in childbirth]. Pregnant women should go to ante- natal [visits], eat well, and go to church and pray a lot to offset [evil] against them to have a safe delivery.”- Skilled health personnel delivery, participant 11 “It might be that it is the person’s destiny. People cast spells to intentionally kill pregnant women to hurt the family. The hospital can’t help you if someone casts a spell on you. You need to go the fetish priest.” -Non- skilled delivery, participant 20 INDIVIDUAL BELIEFS PERCEIVED SUSCEPTIBILITY, SEVERITY, AND THREAT Women were asked questions about their belief in personal susceptibility to childbirth complications and the impor- tance of using skilled health personnel for childbirth deliv- ery. A question exploring beliefs of severity was excluded after field-testing the interview guide and consulting local researchers. We were informed that women often hold su- perstitions; it is ‘bad luck’ to discuss adverse outcomes such as maternal death when implicating self. Generally, women who delivered with skilled health per- sonnel and a few who did not deliver utilising skilled health personnel indicated they believed every woman is suscepti- Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 5 Table 3. Principal results based on Health Belief Model of rural Ghanaian mothers who gave birth in the previous two years, by utilisation of skilled health personnel for delivery Health Belief Model Construct Women who utilised skilled health personnel for delivery Women who did not utilise skilled health personnel for delivery Important differences between groups Notes Modifying Factors (other than demographics) Knowledge/awareness Aware of recommended guidelines to utilise skilled health personnel for delivery most most Fewer were aware among those who did not utilise skilled health personnel for delivery Knowledge of where to obtain maternal health services most most Maternal death causes/ prevention themes: belief in physical, spiritual, and behavioural factors most most Individual Beliefs Perceived susceptibility, severity, and threat Believe it is possible she could suffer a complication during childbirth most split x More than half of mothers who did not utilise skilled health personnel responded 'no' Believe it is important to deliver utilising skilled health personnel most split x More than half of mothers who did not utilise skilled health personnel said, 'it is only important for those with complications' Perceived benefits Believe there are benefits to skilled delivery most most Themes: Skilled health personnel have expertise, medications, and can solve complications most most Perceived barriers Think there are barriers to skilled delivery most most Themes: Cost, distance, and transportation most most Sub-theme: mistreatment or neglect by health staff some some Perceived self-efficacy Capability to adhere to guidelines to utilise skilled health personnel for delivery, overcoming obstacles of transportation and cost most few x Action Cues to action (taken in last pregnancy) Enroll in free maternal health insurance most most Attend 4+ antenatal visits most most Planned and prepared for delivery utilising skilled health personnel most few x Most=approximately 75% or more; Split=approximately 50%; some=approximately >25% and <50%; few=approximately 25% or fewer ble to complications and that it is essential for every woman to deliver with skilled health personnel. “Yes, every woman can have it–complications can occur even if she does not expect it.” -Skilled health person- nel delivery, participant 9 Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 6 Figure 2. Comparison of rural Ghanaian mothers who did and did not utilise skilled health personnel for childbirth delivery, by Health Belief Model construct. Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 7 https://www.joghr.org/article/29883-using-the-health-belief-model-to-explore-rural-maternal-utilisation-of-skilled-health-personnel-for-childbirth-delivery-a-qualitative-study-in-three/attachment/75766.png “Yes, it [skilled health personnel delivery] is important for all women. They have medications that can help you, if needed .”-Skilled health personnel delivery, par- ticipant 14 In contrast, most women who had not delivered with skilled health personnel did not believe they were suscep- tible to complications related to childbirth or that the risk was very low due to antenatal healthcare visits, previous uncomplicated delivery, or spiritual practices. Regarding the importance of utilising skilled health personnel for de- livery, women who did not use skilled health personnel for delivery initially responded “yes” although a few responded “no.” However, upon probing, we found that most women who did not utilise skilled health personnel for delivery be- lieved it is only important if women are told at antenatal care visits that they have a complication that requires hos- pital delivery. “If you go to antenatal, they can see all complications and solve them. Women who don’t go to antenatal care, they don’t know that they have complications, so when they deliver their baby in the house, they bleed, and they die.” -Non-skilled delivery, participant 12 “It is [a complication] possible but less likely, since I haven’t had any complications with my other deliver- ies.” -Nonskilled delivery, participant 23 “No [I am not susceptible to complications], I fortify myself spiritually.”-Nonskilled Delivery, participant 18 “If you don’t have any complications then you can de- liver in the house.” -Nonskilled delivery, participant 19 Additionally, some women who did not utilise skilled health personnel believed it was necessary only for those who did not fortify themselves spiritually through spiritual practices. “Only those who don’t fortify themselves spiritually go to the hospital.” -Nonskilled delivery, participant 16 PERCEIVED BENEFITS Women were asked if they believe there are benefits to de- livery with skilled health personnel. Most women responded that they believed there were benefits to delivering with skilled health personnel, includ- ing that skilled health personnel had knowledge and ex- pertise in childbirth, the ability to solve complications, and give medications, intravenous fluids, and blood transfu- sions if necessary. There were no major differences ob- served between groups. “Nurses can give you medications and solve complica- tions.”- Skilled health personnel delivery, participant 9 “The nurses have a lot of knowledge, and they can give you IV fluids when you need it or transfuse you if needed.” Non-skilled delivery, participant 7 PERCEIVED BARRIERS Women were asked questions regarding the main barriers for women to deliver with skilled health personnel. Common barriers indicated by both women who had and had not delivered utilising skilled health personnel include cost, transportation, and distance. Additionally, perceived possible mistreatment or neglect by health staff was a bar- rier mentioned by some women who had and had not deliv- ered with skilled health personnel. The most common barrier mentioned was associated costs of delivering with skilled health personnel not covered by maternal health insurance. Costs mentioned include a list of required items by the health system a woman should bring for skilled delivery care, food, and transportation. Women also reported transportation and distance as barri- ers due to the difficulty of arranging transport, particularly at night and the mode, which is usually a motorcycle. “If you have to deliver in the hospital, they can give you a long list of things you must buy like towels, powder, bleach. Some women don’t have the money, but others also have money but can’t go because if the labor falls in the night, you can’t get a lorry.” -Non-skilled deliv- ery, participant 15 Perceptions of potential mistreatment during childbirth included forms of physical, verbal, or neglect mistreatment by health staff. “In the hospital, women are mistreated and yelled at, and treated with a lot of impatience.” -Non -skilled de- livery, participant 3 “Some midwives at the CHPS treat you well and some don’t. They can neglect you to develop complications.” -Non-skilled Delivery, participant 12 “The nurses sometimes cane women when they are screaming in labor.” -Skilled health personnel delivery, participant 5 A few women who did not utilise skilled health personnel for delivery cited barriers of lack of birth position options or belief that health personnel would perform an unnecessary cesarean section. “I can’t deliver lying on my back as the nurses require.” -Non-skilled delivery, participant 23 “If you go to deliver in the hospital, even if it is not nec- essary, they will do a cesarean.” -Non-skilled delivery, participant 18 PERCEIVED SELF-EFFICACY We asked women to rate themselves in their confidence to adhere to recommendations to uptake skilled health per- sonnel delivery, including overcoming obstacles of cost and transportation. Most women who utilised skilled health personnel deliv- ery reported ‘high’ self-efficacy to overcome cost and trans- portation obstacles to obtain skilled health personnel deliv- ery. In comparison, most women in the nonskilled delivery group reported ‘low’ self-efficacy due to the cost of items or lack of transportation. The few women reporting ‘high’ self- efficacy indicated they could overcome obstacles to uptake skilled health personnel delivery if necessary. Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 8 ACTION CUES TO ACTION Women were asked questions about their actions taken re- lated to birth preparedness. Most women who delivered with skilled health personnel prepared for birth in advance. Women reported husbands and themselves saving money, buying items on the list re- quired for delivery, husbands arranging transportation in advance, and planning other children’s care. “My husband saved money and gave it to me. Further- more, I also saved money. I bought the items on the list, and my husband made arrangements for transportation for me in advance” -Skilled health personnel delivery, participant 1 By comparison, most women who did not utilise skilled health personnel delivery did not take any actions to pre- pare for birth using skilled health personnel. A few women indicated they would have prepared for the delivery utilis- ing skilled health personnel if not for the lack of financial resources. “No [I did not prepare for skilled health personnel de- livery], I knew I could deliver at home.” -Non-skilled delivery, participant 23 “I didn’t have the money to buy the items on the list re- quired to be bought. If I had money to buy the items, I would go.” -Non-skilled delivery, participant 12 DISCUSSION This study provides insight using a theoretical model to re- veal differences between rural women who utilise skilled health personnel for childbirth and those who do not. Our research shows that rural women differed on the HBM con- structs of perceived susceptibility for complications during childbirth, perceived self-efficacy to overcome barriers for skilled health personnel delivery, and cues to the action of birth preparedness for skilled health delivery. Women in both groups generally agreed on common benefits of skilled health personnel expertise, medications, and the ability to solve complications and agreed on barriers of cost, distance, transportation, and mistreatment by some health staff. THE CRITICAL ROLE OF KNOWLEDGE AND SUSCEPTIBILITY A key difference between women who did and did not utilise skilled health personnel for delivery was perceived suscep- tibility to complications and, subsequently, the importance of skilled health personnel delivery. Our research suggests that knowledge of maternal risk may alter perceptions of vulnerability. We found that women who did not believe they were susceptible to complications lacked knowledge of childbirth risk, overly trusted antenatal care visits to detect complications, thought skilled delivery unnecessary unless informed during antenatal visits of a complication, or be- lieved spiritual rituals practised during pregnancy would ensure safe delivery. These findings agree with other studies that knowledge is an important factor in the uptake of skilled delivery care, often referred to as lack of health liter- acy, low perceived need, or lack of seriousness.21–25 This study differs in that it identifies specific compo- nents of maternal knowledge as influencing perceptions of “susceptibility,” underscoring the importance of maternal understanding of risk. The essential course of action is util- ising skilled delivery care, irrespective of other actions re- lated to individual beliefs. It also adds insight to the per- plexing pattern as to why some rural women adhere to recommended guidelines to uptake antenatal care but not skilled delivery care, as seen in Ghana26 and other coun- tries.27,28 Similarly, Wallace found that rural women and their husbands may perceive antenatal care assuring a healthy pregnancy means everything is fine. Therefore, it is unnecessary to seek skilled health services for labour and delivery.29 While knowledge is essential, an intervention aimed at singularly increasing maternal knowledge is likely to have limited impact in increasing births attended by skilled health personnel21,30 since decision making for childbirth is often determined by or influenced by others.29,31 A more effective approach would likely be to increase community knowledge, including influencers such as community and traditional leaders, religious leaders, elders, men, and other women who women may rely on for social, spiritual, or fi- nancial support.23 WEIGHING BENEFITS AND BARRIERS We found that women from both groups generally agreed on common perceived benefits and barriers. Our findings sug- gest that maternal risk knowledge may affect the weights of perceived benefits and barriers of skilled health personnel delivery.16 This finding may provide insight into why some women seek skilled health personnel delivery while oth- ers do not in the same setting facing similar barriers. Sup- pose women and their families are educated to know that all women are susceptible to unanticipated complications dur- ing childbirth that may result in the mother’s death unless treated promptly by skilled health personnel. In that case, they may be willing to take actions to overcome barriers to minimise risk, such as allocating financial resources for the benefit of skilled health personnel delivery, while those who do not know maternal risk may be less willing. BARRIERS OF COST AND ACCESS PERSIST Our study found that cost and access barriers too substan- tial to overcome persist for some rural women, even though Ghana provides free coverage of maternal health services, including delivery with skilled health personnel,14 and ex- panded maternal health services to rural areas through the CHPS program.12 Women cited barriers of lack of money for associated costs of skilled health personnel delivery, such as the cost of the items required by GHS and transportation, a finding corroborated in a recent study by Boah.32 These findings suggest that the least advantaged women may be too poor to access skilled health personnel delivery. Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 9 BARRIERS BEYOND COST AND ACCESS We found that while women valued skilled health personnel expertise and medical interventions, the possibility of mis- treatment during labour and childbirth by some health staff was a barrier cited by both groups of women. Possible mis- treatment by health staff was a barrier that influenced women’s choice of nonskilled delivery over skilled delivery care, exemplified by the following quotes, “Some midwives at the CHPS treat you well and some don’t. They can neglect you to develop complications” (nonskilled delivery, partic- ipant 12) and “In the hospital, women are mistreated and yelled at, and treated with a lot of impatience” (nonskilled delivery, participant 3). Other studies have reported mis- treatment of women during childbirth is common.33,34 Ad- ditionally, the lack of birthing position options and fear of unnecessary cesarean were barriers for a few women. These findings provide insight into why some women, even when cost and access barriers have been addressed, do not uptake skilled delivery care. A health system intervention of train- ing healthcare workers in interpersonal relations may be a feasible approach to increasing the respectful treatment of women. IMPLICATIONS Improving births attended by skilled health personnel is a multifaceted issue and may require a combination of ef- forts at the community, health system, and national levels, depending on the context. Interventions should aim to in- crease community knowledge of maternal risk during child- birth, the importance of skilled health personnel delivery, overcoming barriers, and birth preparedness, as decision making occurs in the context of the community and women often need support from men and others to uptake skilled health personnel delivery. Previous research has shown that community-based interventions may be effective at in- creasing maternal utilisation of skilled health personnel for delivery.35–37 This research points to the health system’s tremendous opportunity to improve maternal health outcomes at sev- eral different leverage points. First, there is an opportunity to engage communities to increase community knowledge of maternal risk and overcome barriers to access skilled health personnel delivery. Second, antenatal care visits pro- vide an opportunity to reinforce messaging of the impor- tance of delivery with skilled health personnel, to educate women on maternal health, and work with women and their partners to increase birth preparedness. Third, there is an opportunity for the health system to improve women’s childbirth experience by training health staff on interper- sonal skills and implementing policies that promote a com- fortable and supportive environment for women during childbirth. At the national level, pro-equitable policies should be es- tablished, providing pathways to overcome barriers to ac- cess skilled health personnel delivery care for the least ad- vantaged women, including subsidising the cost of supplies women are required to bring to the health facility for child- birth. Finally, countries must plan strategically to improve education levels for both girls and boys and reduce poverty in rural populations by increasing economic opportunities since both are strong determinants of skilled delivery care uptake. Further research should focus on developing com- munity-based interventions to increase birth preparedness, approaches to improving health staff treatment of women, and reducing inequities to ensure all women, including the least advantaged, benefit from skilled health personnel de- livery. STRENGTHS AND LIMITATIONS To our knowledge, this is the first study to identify key dif- ferences between groups of rural women residing in the same setting who did and did not utilise skilled health per- sonnel delivery using a theory-based model. The study identifies the constructs of perceived risk for complications during childbirth, perceived self-efficacy to overcome barri- ers of cost and transportation, and cues to action of plan- ning and preparing in advance for delivery utilising skilled health personnel as key differences and important factors of whether a woman will utilise skilled health personnel for delivery. Furthermore, this research provides valuable insight for policy makers and program planners into potential leverage areas for creating pro-equitable policies and designing fu- ture interventions. Despite strengths of the research, there are some limitations. Although comparison of groups is beneficial to identify important differences between and within groups, there is currently no standardised method- ology for making comparison in qualitative research.38 We cannot rule out the possibility of selection and recall bias. It is possible participants may not have accurately recalled information, or that they did not fully share information, or that women may have selectively rejected participation since maternal attitudes and experiences may be a sensitive topic for women. Additionally, we faced limitations inher- ent in conducting a collaborative study in a low-resource setting, including time constraints which is why researchers coded and generated themes together arriving at consen- sus, rather than independently-although we made efforts to limit bias by reviewing the data texts and themes several times. Furthermore, findings from this study may be spe- cific to this area and not transferrable. There is a need for confirmation of results in future research including through larger quantitative studies to measure effect and impact. CONCLUSIONS Application of the Health Belief Model reveals both com- monalities and key differences in perceptions and behav- iours between groups of women residing in the same rural setting who did and did not deliver utilising skilled health personnel, providing valuable insight for policymakers, the health system, and program managers. Policies and inter- ventions should focus on increasing maternal knowledge and perceptions of risk, the importance of skilled health de- livery, birth preparedness, and overcoming cost and access barriers that still persist for some rural women. The main similarities between both groups of women in- cluded that both were aware that the health system rec- Using the Health Belief Model to explore rural maternal utilisation of skilled health personnel for childbirth delivery: a... Journal of Global Health Reports 10 ommends women deliver utilising skilled health personnel. Both perceived that main barriers to skilled health delivery included cost, transportation, and distance while the main benefits were that skilled health personnel have childbirth expertise and knowledge, access to medications, and the ability to solve complications. Key differences between groups of women included perceived risk of experiencing complications during childbirth and importance of deliver- ing with skilled health personnel, perceived self-efficacy to overcome barriers, and birth preparedness–although some women in the group not utilising skilled health personnel had risk perceptions similar to those who utilised skilled health delivery, but believed the barriers they faced as too substantial to overcome for them to utilise skilled health personnel for delivery. Thus, this research also provides in- sight into why maternal rural utilisation rates of skilled health personnel for delivery are suboptimal despite com- mendable country efforts to reduce cost and access barriers. ACKNOWLEDGEMENTS We express gratitude to Ensign Global College administra- tion and staff for logistic support and to Ghana Health Ser- vices, the District Health Directors, and health personnel for their assistance in selecting the study communities and coordinating the research with communities. Additionally, we wish to thank Health 2 Go for coordination efforts, re- cruiting our research team in Ghana, and for their support in carrying out this international study. We thank our entire research team for their dedication and commitment. Fi- nally, we wish to thank the communities and women who participated in the study from the Eastern Region in Ghana. FUNDING This study was funded by Cast a Pebble Foundation. AUTHORSHIP CONTRIBUTIONS Study design: JN, SA; data collection and analysis: JN, RA, YA; writing: JN; review and revision of study design, manu- script drafts, and approval of the final manuscript: JN, TD, LG, SB, SM, and SA. COMPETING INTERESTS The authors completed the Unified Competing Interest form at http://www.icmje.org/disclosure-of-interest/ (available upon request from the corresponding author) and declare no conflicts of interest. CORRESPONDENCE TO: Jeanette R Nelson, PhD Center for Business, Health, and Prosperity, David Eccles School of Business University of Utah, Salt Lake City, Utah, USA Jeanette.r.nelson@utah.edu Submitted: September 29, 2021 GMT, Accepted: October 21, 2021 GMT This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CCBY-4.0). 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Journal of Global Health Reports 13 https://doi.org/10.1186/s13643-017-0503-x https://doi.org/10.1186/s13643-017-0503-x https://doi.org/10.1186/s12884-018-1749-6 https://doi.org/10.1186/s12884-015-0695-9 https://doi.org/10.1186/s12884-015-0695-9 https://doi.org/10.1186/1471-2393-10-13 https://doi.org/10.1186/1471-2393-10-13 https://doi.org/10.1016/j.midw.2018.05.013 https://doi.org/10.1186/s12913-016-1632-y https://doi.org/10.1186/s12913-016-1632-y https://doi.org/10.1111/birt.12404 https://doi.org/10.1371/journal.pone.0230341 https://doi.org/10.1371/journal.pone.0230341 https://doi.org/10.1186/1471-2458-5-140 https://doi.org/10.1186/1471-2458-5-140 https://doi.org/10.1371/journal.pmed.1001847 https://doi.org/10.1371/journal.pmed.1001847 https://doi.org/10.1093/heapol/czx045 https://doi.org/10.1186/1471-2431-14-187 https://doi.org/10.1371/journal.pmed.1001881 Background Methods Results Conclusions Ghana context Research needed Health Belief Model METHODS Study design Research setting Study population Data collection Data analysis RESULTS Characteristics of participants Findings related to the Health Belief Model Modifying factors Knowledge and awareness Individual beliefs Perceived susceptibility, severity, and threat Perceived benefits Perceived barriers Perceived self-efficacy Action Cues to action DISCUSSION The critical role of knowledge and susceptibility Weighing benefits and barriers Barriers of cost and access persist Barriers beyond cost and access Implications Strengths and limitations CONCLUSIONS Acknowledgements Funding Authorship contributions Competing interests Correspondence to: References