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Open Access Research article

Lessons learned in Liberia: preliminary examination of the psychometric properties of trust and teamwork among maternal healthcare workers

Jody R Lori1*, Michelle L Munro1, Jennifer E Moore2 and Jessica Fladger1

Author Affiliations

1 Division of Health Promotion and Risk Reduction, University of Michigan, School of Nursing, 400 N. Ingalls, Room 3352, Ann Arbor, MI 48109, USA

2 Division of Nursing Business and Health Systems, University of Michigan, School of Nursing, 400 N. Ingalls, Room 4170, Ann Arbor, MI 48109, USA

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BMC Health Services Research 2013, 13:134  doi:10.1186/1472-6963-13-134

Published: 11 April 2013



Post-conflict Liberia has one of the fastest growing populations on the continent and one of the highest maternal mortality rates among the world. However, in the rural regions, less than half of all births are attended by a skilled birth attendant. There is a need to evaluate the relationship between trained traditional healthcare providers and skilled birth attendants to improve maternal health outcomes. This evaluation must also take into consideration the needs and desires of the patients. The purpose of this pilot study was to establish the validity and reliability of a survey tool to evaluate trust and teamwork in the working relationships between trained traditional midwives and certified midwives in a post-conflict country.


A previously established scale, the Trust and Teambuilding Scale, was used with non- and low-literate trained traditional midwives (n=48) in rural Liberia to evaluate trust and teamwork with certified midwives in their communities. Initial results indicated that the scale and response keys were culturally inadequate for this population. A revised version of the scale, the Trust and Teamwork Scale – Liberia, was created and administered to an additional group of non- and low-literate, trained traditional midwives (n=42). Exploratory factor analysis using Mplus for dichotomous variables was used to determine the psychometric properties of the revised scale and was then confirmed with the full sample (n=90). Additional analyses included contrast validity, convergent validity, and Kuder-Richardson reliability.


Exploratory factor analysis revealed two factors in the revised Trust and Teamwork Scale – Liberia. These two factors, labeled trust and teamwork, included eleven of the original eighteen items used in the Trust and Teamwork Scale and demonstrated contrast and convergent validity and adequate reliability.


The revised scale is suitable for use with non- and low-literate, trained traditional midwives in rural Liberia. Continued cross-cultural validation of tools is essential to ensure scale adequacy across populations. Future work should continue to evaluate the use of the Trust and Teamwork Scale – Liberia across cultures and additional work is needed to confirm the factor structure.

Trust; Teamwork; Traditional birth attendants; Certified midwives; Psychometric testing