1
|
Wakiaga JM, Nalugala R. An examination of the structural linkages between households and community health services in realization of accelerated primary healthcare delivery in Kisumu County, Kenya: a systematic review. F1000Res 2024; 10:1082. [PMID: 39007092 PMCID: PMC11240083 DOI: 10.12688/f1000research.73303.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Background The provision of community health services (CHS) is critical in accelerating primary health care delivery to vulnerable and deprived populations. This systematic review study has been conducted to interrogate the interrelationship between households and community health services in accelerating primary healthcare delivery synthesizing the available empirical studies. The findings are to inform a primary research on structural linkages between households and CHS in Kisumu County, Kenya. Methods This study applied a descriptive approach using a systematic review technique to provide context and substance to the two main research questions: (1) how does the interaction between households and CHWs affect utilization of CHS to promote equity and right to health? (2) How do health-seeking behaviours of households influence their decision-making regarding choices of CHS? We screened the literature from Google scholar, JSTOR, SAGE and EBSCO based on our inclusion criteria, resulting in 21 studies. These studies were assessed for quality and eligibility and data extracted based on relevance to the research study. Results Households place primacy on trust and confidentiality in the interaction with CHWs and this affects uptake of CHS. The social determinants of health are also critical in influencing the health-seeking behaviour of households and individuals and their choice of CHS. The successful models of CHS share the characteristic of community ownership and participation and provides for comprehensive health care teams. Conclusion CHS are critical for the acceleration of primary health care delivery. It forms an important pathway for the achievement of universal health coverage, which is an outcome required for Sustainable Development Goal 3 on health.
Collapse
Affiliation(s)
- James M. Wakiaga
- Institute of Social Transformation, Tangaza University College, Tangaza University College, Nairobi, Kenya
| | - Reginald Nalugala
- Institute of Social Transformation, Tangaza University College, Tangaza University College, Nairobi, Kenya
| |
Collapse
|
2
|
Ebob Besem E O M, Chestnutt EG, Donovan L, Stratil AS, Counihan H, Nkfusai CN, Hawkings H, Homolova B, Maxwell K, Baker K, Zoungrana Y, Tanue EA, Ayuk G, Modjenpa NB, Metuge A, Nganmou I, Achu D, Wanji S, Berryman E, Omam LA. Exploring existing malaria services and the feasibility of implementing community engagement approaches amongst conflict-affected communities in Cameroon: a qualitative study. Malar J 2024; 23:155. [PMID: 38769514 PMCID: PMC11107007 DOI: 10.1186/s12936-024-04934-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Cameroon is one of the countries with the highest burden of malaria. Since 2018, there has been an ongoing conflict in the country, which has reduced access to healthcare for populations in affected regions, and little is known about the impact on access to malaria services. The objective of this study was to understand the current situation regarding access to malaria services in Cameroon to inform the design of interventions to remove barriers and encourage the use of available services. METHODS A qualitative research study was carried out to understand the barriers preventing communities accessing care, the uptake of community health worker (CHW) services, and to gather perceptions on community engagement approaches, to assess whether these could be an appropriate mechanism to encourage uptake of community health worker (CHW) services. Twenty-nine focus group discussions and 11 in-depth interviews were carried out between May and July 2021 in two regions of Cameroon, Southwest and Littoral. Focus group discussions were held with CHWs and community members and semi-structured, in-depth interviews were conducted with key stakeholders including regional government staff, council staff, community leaders and community-based organisations. The data were analysed thematically; open, descriptive coding was combined with exploration of pre-determined investigative areas. RESULTS The study confirmed that access to healthcare has become increasingly challenging in conflict-affected areas. Although the Ministry of Health are providing CHWs to improve access, several barriers remain that limit uptake of these services including awareness, availability, cost, trust in competency, and supply of testing and treatment. This study found that communities were supportive of community engagement approaches, particularly the community dialogue approach. CONCLUSION Communities in conflict-affected regions of Cameroon continue to have limited access to healthcare services, in part due to poor use of CHW services provided. Community engagement approaches can be an effective way to improve the awareness and use of CHWs. However, these approaches alone will not be sufficient to resolve all the challenges faced by conflict-affected communities when accessing health and malaria services. Additional interventions are needed to increase the availability of CHWs, improve the supply of diagnostic tests and treatments and to reduce the cost of treatment for all.
Collapse
Affiliation(s)
- Margaret Ebob Besem E O
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, Cameroon
| | | | - Laura Donovan
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Ann-Sophie Stratil
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Helen Counihan
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Claude Ngwayu Nkfusai
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
- Department of Public Health, School of Nursing and Public Health, University of Kwa-Zulu Natal, Durban, South Africa
| | - Helen Hawkings
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Blanka Homolova
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Kolawole Maxwell
- Malaria Consortium Nigeria, No 33 Pope John Paul Street, Off Gana Street, Maitama, Abuja, FCT, Nigeria
| | - Kevin Baker
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
- Karolinksa Institute, Nobels Väg 15 A, 171 77, Stockholm, Sweden
| | - Yakouba Zoungrana
- Malaria Consortium Nigeria, No 33 Pope John Paul Street, Off Gana Street, Maitama, Abuja, FCT, Nigeria
| | - Elvis Asangbeng Tanue
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, Cameroon
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
| | - Glennise Ayuk
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
| | | | - Alain Metuge
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
| | | | - Dorothy Achu
- National Malaria Control Programme, Ministry of Public Health, Yaoundé, Cameroon
| | - Samuel Wanji
- Department for Microbiology and Parasitology at the University of Buea, Buea, Cameroon
- Research Foundation in Tropical Diseases and Environment, Buea, Cameroon
| | - Elizabeth Berryman
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK.
| | - Lundi-Anne Omam
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
3
|
Fitzpatrick KM, Sjoblom E, Puinean G, Robson H, Campbell SM, Fayant B, Montesanti S. Examining global Indigenous community wellness worker models: a rapid review. Int J Equity Health 2024; 23:90. [PMID: 38698390 PMCID: PMC11065687 DOI: 10.1186/s12939-024-02185-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/22/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND There is a growing interest in employing community wellness worker models in Indigenous populations to address inequities in healthcare access and outcomes, concerns about shortage in health and mental health human resources, and escalating burden of chronic and complex diseases driving significant increase in health services demand and costs. A thorough review of Indigenous community wellness worker models has yet to be conducted. This rapid review sought to outline the characteristics of a community wellness worker model in Indigenous contexts across the globe, detailing factors shaping implementation challenges and success. METHODS A rapid review of the international peer-reviewed and grey literature of OVID Medline, Global Index Medicus, Google, and Google Scholar was conducted from January to June 2022 for Indigenous community wellness/mental health worker models and comparative models. Articles were screened and assessed for eligibility. From eligible articles, data pertaining to study design and sample; description of the program, service, or intervention; model development and implementation; terminology used to describe workers; training features; job roles; funding considerations; facilitators and barriers to success; key findings; outcomes measured; and models or frameworks utilized were extracted. Data were synthesized by descriptive and pattern coding. RESULTS Twenty academic and eight grey literature articles were examined. Our findings resulted in four overarching and interconnected themes: (1) worker roles and responsibilities; (2) worker training, education, and experience; (3) decolonized approaches; and (4) structural supports. CONCLUSION Community wellness worker models present a promising means to begin to address the disproportionately elevated demand for mental wellness support in Indigenous communities worldwide. This model of care acts as a critical link between Indigenous communities and mainstream health and social service providers and workers fulfill distinctive roles in delivering heightened mental wellness supports to community members by leveraging strong ties to community and knowledge of Indigenous culture. They employ innovative structural solutions to bolster their efficacy and cultivate positive outcomes for service delivery and mental wellness. Barriers to the success of community wellness worker models endure, including power imbalances, lack of role clarity, lack of recognition, mental wellness needs of workers and Indigenous communities, and more.
Collapse
Affiliation(s)
- Kayla M Fitzpatrick
- School of Public Health, University of Alberta, 3-300 Eddmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada
| | - Erynne Sjoblom
- School of Public Health, University of Alberta, 3-300 Eddmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada
| | - Giulia Puinean
- School of Public Health, University of Alberta, 3-300 Eddmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada
| | - Heath Robson
- School of Public Health, University of Alberta, 3-300 Eddmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, Mackenzie Health Science Centre, University of Alberta, 8440 - 112 St, Edmonton, AB, T6G 2B7, Canada
| | - Bryan Fayant
- McMurray Métis Local 1935, 441 Sakitawaw Trail, Fort McMurray, AB, AB T9H 4P3, Canada
| | - Stephanie Montesanti
- School of Public Health, University of Alberta, 3-300 Eddmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada.
- Centre for Healthy Communities, School of Public Health, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
4
|
Ndambo MK, Aron MB, Makungwa H, Munyaneza F, Nhlema B, Connolly E. Perspectives of community and facility stakeholders on community health workers in rural Malawi. Afr J Prim Health Care Fam Med 2024; 16:e1-e11. [PMID: 38426769 PMCID: PMC10913143 DOI: 10.4102/phcfm.v16i1.4199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household-level CHW services, in remote areas, to understand CHW's role in community-based PHC. AIM To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community-based PHC in Neno District. SETTING The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa. METHODS We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change. RESULTS Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community-based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community-based PHC. CONCLUSION Community health workers enrich community-based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health-seeking behaviours.Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.
Collapse
|
5
|
Wang X, Fu Q, Zhou M, Li Y. How Integrated Digital Tools Can Improve Tuberculosis Medication Adherence: A Longitudinal Study in China. Telemed J E Health 2024; 30:490-498. [PMID: 37498525 DOI: 10.1089/tmj.2023.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
Background: Poor medication adherence remains one of the major problems in the treatment of tuberculosis (TB) patients, while digital technologies have been proven effective to improve the treatment results. However, reports on the effectiveness of comprehensive practice integrating different intervention methods and technologies are limited. The aim of this study is to evaluate the effectiveness of an integrated digital adherence intervention for TB patients. Methods: We developed a digital adherence intervention platform integrating instant WeChat message, electronic medication monitors (EMMs), and manual reminders. The primary goal of the platform was to improve the accessibility of digital adherence technologies, and thus improve treatment adherence. TB patients were newly diagnosed at 10 TB-designated hospitals and came from 220 communities, from January to June 2022. The basic characteristics and treatment adherence of TB patients in WeChat, EMM, and conventional groups were compared, and the influencing factors of high medication adherence were analyzed by logistic regression. Results: A total of 2,498 TB patients were enrolled in the study, 14.5% were managed by digital technologies, 9.5% by WeChat, and 5.0% by EMM, respectively. After intervention, the median medication rate of TB patients was significantly higher in the WeChat group (95.3%) and EMM group (95.7%) compared with that of the conventional group (83.8%). On the contrary, the median number of missed medications among patients of the conventional group (nine times) was significantly higher than that in the WeChat (three times) group and EMM (three times) group. The proportion of high adherence (adherence medication rate ≥90%) among TB patients was 64.7%, 64.5%, and 43.2% in WeChat, EMM, and conventional group, respectively. Conclusions: The application of the integrated digital adherence intervention platform could significantly improve medication adherence among TB patients. The accessibility of digital adherence technologies could be improved by integrating complementary technologies in practice.
Collapse
Affiliation(s)
- Xiaojun Wang
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Qian Fu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meilan Zhou
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Yuehua Li
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| |
Collapse
|
6
|
Palomares Velosa JE, Figueroa Gómez JE, Rojas Zúñiga CN, Díaz G, Ferro BE, Davis JL, Grau LE. Exploring stakeholders perspectives on TB contact investigation in Cali, Colombia: a qualitative study. Front Public Health 2023; 11:1204862. [PMID: 37564424 PMCID: PMC10411903 DOI: 10.3389/fpubh.2023.1204862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction Contact investigation is a proven intervention for tuberculosis (TB) case finding and prevention. Although widely endorsed by national public health authorities and the World Health Organization, many countries struggle to implement it effectively. The objective of the study is to describe and characterize the barriers and facilitators of TB contact investigation in Cali, Colombia from the perspective and experience of the key stakeholders involved. Methods We collected data from group discussions during two workshop sessions with clinic and public health staff involved in TB contact investigation (June 2019 and March 2020 respectively) and semi-structured interviews with TB cases and their household contacts (July 2019 to April 2020). We undertook an inductive thematic analysis with the RADaR technique to characterize the barriers and facilitators of the TB contact investigation process. Results The two workshops included 21 clinics and 12 public health staff. We also conducted 26 semi-structured interviews with TB cases and their household contacts. Using thematic analysis, we identified four common themes: Healthcare Operations, Essential Knowledge, Time Limitations and Competing Responsibilities, and Interpersonal Interactions. The main barriers to conducting household visits were low data quality, stigma and mistrust, safety concerns for health workers, and limited resources. The main barriers to TB uptake by contacts were competing responsibilities, low TB risk perceptions among contacts, and difficulty accessing diagnostic tests for contacts. In contrast, good communication and social skills among health workers and accurate TB knowledge facilitated successful household visits and TB test uptake, according to key stakeholders. Conclusion This study provides a deeper understanding of TB contact investigation barriers and facilitators in a high-prevalence urban setting in a middle-income country from the perspective and experience of key stakeholders. The study shed light on the barriers that hinder household contacts engagement and TB test uptake such as issues of systemic capacity and TB knowledge. Also, highlighted facilitators such as the importance of interpersonal communication skills among health workers in the public and private sector. The insights from this study can serve as a valuable resource for public health organizations seeking to enhance their contact investigation efforts and improve TB control in similar settings.
Collapse
Affiliation(s)
- Jairo E. Palomares Velosa
- Centro Internacional de Entrenamiento e Investigaciones Médicas – CIDEIM, Cali, Valle del Cauca, Colombia
- Universidad Icesi, Cali, Valle del Cauca, Colombia
| | | | | | - Gustavo Díaz
- Centro Internacional de Entrenamiento e Investigaciones Médicas – CIDEIM, Cali, Valle del Cauca, Colombia
- Universidad Icesi, Cali, Valle del Cauca, Colombia
| | - Beatriz E. Ferro
- Departamento de Ciencias Básicas Médicas, Universidad Icesi, Cali, Valle del Cauca, Colombia
| | - J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
- Pulmonary Critical Care and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, United States
| | - Lauretta E. Grau
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
| |
Collapse
|
7
|
Knettel BA, Muhirwa A, Wanda L, Amiri I, Muiruri C, Fernandez KM, Watt MH, Mmbaga BT, Relf MV. Patient perspectives on the helpfulness of a community health worker program for HIV care engagement in Tanzania. AIDS Care 2023; 35:1014-1021. [PMID: 34702095 PMCID: PMC9038954 DOI: 10.1080/09540121.2021.1995840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 10/14/2021] [Indexed: 10/20/2022]
Abstract
Task-shifting is a valuable approach for redistributing clinical tasks to nonprofessional health workers and relieving human resource shortages. The Community-Based HIV Services (CBHS) program is a national cohort of volunteer community health workers (CHWs) who support HIV care engagement at clinics in Tanzania. We recruited 23 patients initiating HIV care at two clinics to understand their experiences with the CBHS program. Participants completed qualitative interviews by telephone discussing the perceived helpfulness of the program, their level of connection with CHWs, and suggestions for improvement. Data were analyzed through an inductive, team-based qualitative approach. Most participants found the program to be helpful and described close, positive connections. CHWs offered education, emotional support to accept one's diagnosis and cope with stigma, and encouragement to remain engaged in HIV care. However, several participants described minimal, shallow contact with CHWs, and felt the program did not benefit their HIV care. Participants recommended increasing CHW efforts to engage people living with HIV (PLWH) in the broader community, and addressing socioeconomic barriers to care engagement. When contacts are consistent, the CBHS program is a strong resource for PLWH. To maximize the potential of the program, administrators should enhance oversight and extend new training opportunities for CHWs.
Collapse
Affiliation(s)
- Brandon A. Knettel
- Duke University School of Nursing, Durham, NC
- Duke Global Health Institute, Duke University, Durham, NC
| | | | - Lisa Wanda
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Ismail Amiri
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Charles Muiruri
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Kimberly M. Fernandez
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Melissa H. Watt
- Duke Global Health Institute, Duke University, Durham, NC
- Department of Population Health Sciences, The University of Utah School of Medicine
| | - Blandina T. Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University, Moshi, Tanzania
| | - Michael V. Relf
- Duke University School of Nursing, Durham, NC
- Duke Global Health Institute, Duke University, Durham, NC
| |
Collapse
|
8
|
Aron MB, Ndambo MK, Munyaneza F, Mulwafu M, Makungwa H, Nhlema B, Connolly E. A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi. HUMAN RESOURCES FOR HEALTH 2023; 21:51. [PMID: 37365561 DOI: 10.1186/s12960-023-00839-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi. METHODS We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks. RESULTS We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05). CONCLUSION This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.
Collapse
Affiliation(s)
- Moses Banda Aron
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi.
| | | | | | - Manuel Mulwafu
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | - Henry Makungwa
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | | | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, United States of America
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, United States of America
| |
Collapse
|
9
|
Ingenhoff R, Munana R, Weswa I, Gaal J, Sekitoleko I, Mutabazi H, Bodnar BE, Rabin TL, Siddharthan T, Kalyesubula R, Knauf F, Nalwadda CK. Principles for task shifting hypertension and diabetes screening and referral: a qualitative study exploring patient, community health worker and healthcare professional perceptions in rural Uganda. BMC Public Health 2023; 23:881. [PMID: 37173687 PMCID: PMC10176286 DOI: 10.1186/s12889-023-15704-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND A shortage of healthcare workers in low- and middle-income countries (LMICs) combined with a rising burden of non-communicable diseases (NCDs) like hypertension and diabetes mellitus has resulted in increasing gaps in care delivery for NCDs. As community health workers (CHWs) often play an established role in LMIC healthcare systems, these programs could be leveraged to strengthen healthcare access. The objective of this study was to explore perceptions of task shifting screening and referral for hypertension and diabetes to CHWs in rural Uganda. METHODS This qualitative, exploratory study was conducted in August 2021 among patients, CHWs and healthcare professionals. Through 24 in-depth interviews and ten focus group discussions, we investigated perceptions of task shifting to CHWs in the screening and referral of NCDs in Nakaseke, rural Uganda. This study employed a holistic approach targeting stakeholders involved in the implementation of task shifting programs. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically guided by the framework method. RESULTS Analysis identified elements likely to be required for successful program implementation in this context. Fundamental drivers of CHW programs included structured supervision, patients' access to care through CHWs, community involvement, remuneration and facilitation, as well as building CHW knowledge and skills through training. Additional enablers comprised specific CHW characteristics such as confidence, commitment and motivation, as well as social relations and empathy. Lastly, socioemotional aspects such as trust, virtuous behavior, recognition in the community, and the presence of mutual respect were reported to be critical to the success of task shifting programs. CONCLUSION CHWs are perceived as a useful resource when task shifting NCD screening and referral for hypertension and diabetes from facility-based healthcare workers. Before implementation of a task shifting program, it is essential to consider the multiple layers of needs portrayed in this study. This ensures a successful program that overcomes community concerns and may serve as guidance to implement task shifting in similar settings.
Collapse
Affiliation(s)
- Rebecca Ingenhoff
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Richard Munana
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University College of Health Sciences, Makerere University, Kampala, Uganda
- African Community Center for Social Sustainability, Nakaseke, Uganda
| | - Ivan Weswa
- African Community Center for Social Sustainability, Nakaseke, Uganda
| | - Julia Gaal
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Isaac Sekitoleko
- MRC/UVRI and LSHTM Uganda Research Unit, Kampala, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Hillary Mutabazi
- African Community Center for Social Sustainability, Nakaseke, Uganda
| | - Benjamin E Bodnar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy L Rabin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Trishul Siddharthan
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Coral Gables, USA
| | - Robert Kalyesubula
- African Community Center for Social Sustainability, Nakaseke, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Physiology, Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Christine K Nalwadda
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
10
|
Lukyamuzi Z, Ssuna B, Mirembe RN, Mawanda D, Kinkumu P, Nalugo C, Adikin E, Namisango F, Nakalega R, Atuhaire P, Musoke P, Butler LM. Experiences and challenges of using community health worker-led mechanism in supporting HIV disclosure among adults living with HIV in heterosexual relationships in the rural Uganda. AIDS Res Ther 2023; 20:14. [PMID: 36906557 PMCID: PMC10008611 DOI: 10.1186/s12981-023-00508-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/23/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND HIV status disclosure among sexual partners is vital in HIV management. Community health workers (CHW) support HIV disclosure among adults living with HIV (ALHIV) in sexual relationships with disclosure difficulties. However, experiences and challenges of using CHW-led disclosure support mechanism were not documented. This study explored experiences and challenges involved in using CHW-led disclosure support mechanism among ALHIV in heterosexual relationships in the rural Uganda. METHODS This was a phenomenological qualitative study involving in-depth interviews among CHWs and ALHIV with HIV disclosure difficulties to sexual partners in greater Luwero region, Uganda. We conducted 27 interviews among purposively selected CHWs and participants who had participated in the CHW-led disclosure support mechanism. Interviews were conducted until saturation was reached; and analysis was done using inductive and deductive content analysis in Atlas. RESULTS All respondents viewed HIV disclosure as an important strategy in HIV management. Provision of adequate counseling and support to those intending to disclose was instrumental for successful disclosure. However, fear of the negative disclosure outcomes was viewed as a barrier to disclosure. The CHWs were viewed as having an added advantage in supporting disclosure as opposed to the routine disclosure counseling. However, HIV disclosure using CHW-led support mechanism would be limited by possible bleach of client's confidentiality. Therefore, respondents thought that appropriate selection of CHWs would improve their trust in the community. Additionally, providing CHWs with adequate training and facilitation during the disclosure support mechanism was viewed to improve their work. CONCLUSION Community health workers were viewed as being more supportive in HIV disclosure among ALHIV with disclosure difficulties to sexual partners compared to routine facility based disclosure counseling. Therefore, near location CHW-led disclosure mechanism was acceptable and useful in supporting HIV disclosure among HIV-affected sexual partners in rural settings.
Collapse
Affiliation(s)
- Zubair Lukyamuzi
- Johns Hopkins University Collaboration (MU-JHU), Makerere University, Upper Mulago Hill Road, Kampala, Uganda. .,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Bashir Ssuna
- Uganda Tuberculosis Implementation Research Consortium (U-TIRC), Kampala, Uganda
| | - Ruth Nabisere Mirembe
- Infectious Diseases Institute (IDI), College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Mawanda
- Johns Hopkins University Collaboration (MU-JHU), Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Paul Kinkumu
- Mildmay Hospital and Institute of Health Sciences, Mildmay Uganda, Box 24985, Kampala, Uganda
| | - Christine Nalugo
- Mildmay Hospital and Institute of Health Sciences, Mildmay Uganda, Box 24985, Kampala, Uganda
| | - Esther Adikin
- Mildmay Hospital and Institute of Health Sciences, Mildmay Uganda, Box 24985, Kampala, Uganda
| | | | - Rita Nakalega
- Johns Hopkins University Collaboration (MU-JHU), Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Patience Atuhaire
- Johns Hopkins University Collaboration (MU-JHU), Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Philippa Musoke
- Johns Hopkins University Collaboration (MU-JHU), Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Lisa M Butler
- Institute for Collaboration On Health, Intervention, and Policy, University of Connecticut, Storrs, CT, 06269, USA
| |
Collapse
|
11
|
Mogaka JN, Lagat H, Otieno G, Macharia P, Wamuti B, Masyuko S, Sharma M, Kariithi E, Farquhar C, Temu TM. Descriptive study: Feasibility of integrating hypertension screening into HIV assisted partner notification services model in Kenya. Medicine (Baltimore) 2023; 102:e33067. [PMID: 36827044 PMCID: PMC11309717 DOI: 10.1097/md.0000000000033067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/25/2023] Open
Abstract
Prevalence of hypertension (HTN) and human immunodeficiency virus (HIV) are high among men while screening rates are low. Assisted partner notification service is a strategy recommended by the World Health Organization that aims to increase HIV testing and treatment uptake and may present an opportunity to offer integrated HIV/HTN screening and treatment services. In this prospective cohort study, we assessed the feasibility of integrating HTN screening for male sexual partners of females newly tested HIV-positive in 10 health facilities in Kenya. Participants were notified of the exposure and offered HIV testing and HTN screening; if they accepted and tested positive for either HTN, HIV, or both, they were referred for care. HTN was defined as systolic blood pressure ≥ 140 mm Hg, diastolic blood pressure ≥ 90, or the use of antihypertensive medication. Among 1313 male partners traced, 99% accepted HIV testing and HTN screening. Overall, 4% were found to have HTN, 29% were in the pre-HTN stage, and 9% were HIV-positive. Only 75% had previously been screened for HTN compared to 95% who had previously tested for HIV. A majority preferred non-facility-based screening. The participants who refused HTN screening noted time constraints as a significant hindrance. HIV and HTN screening uptake was high in this hard-to-reach population of men aged 25 to 50. Although HTN rates were low, an integrated approach provided an opportunity to detect those with pre-HTN and intervene early. Strategic integration of HTN services within assisted partners services may promote and normalize testing by offering inclusive and accessible services to men.
Collapse
Affiliation(s)
| | | | | | - Paul Macharia
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Sarah Masyuko
- Ministry of Health-National AIDS and STI Control Program, Nairobi, Kenya
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, WA
- Department of Epidemiology and Medicine, University of Washington, Seattle, WA
| | - Tecla M. Temu
- Department of Global Health, University of Washington, Seattle, WA
- Institute of Tropical Diseases, University of Nairobi, Nairobi, Kenya
| |
Collapse
|
12
|
Turpin A, Charest M, Brennan DJ, Griffiths D. Exploring inter- and intra-organisational dynamics supporting task-shifting opportunities in AIDS service organisations: A qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e4724-e4734. [PMID: 35698825 DOI: 10.1111/hsc.13879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/05/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
Task-shifting of combination sexual health services from clinicians to community workers has been well-studied in low-resource settings, but lacks empirical examination as a response to service inequities in North American community-based AIDS service organisations (ASOs). This study adopts a qualitative exploratory approach to understanding how ASOs may support task-shifting for gay, bisexual and other men who have sex with men (GBMSM), drawing from interviews (n = 33) with clinicians and community workers in southern Ontario. Results include intra-organisational (including resource supports, development of community worker roles, providing task-shifting training, provider representation and inclusive service environment) and inter-organisational (including structure of engagement, streamlining referrals, development of effective partnerships, development of a formal organisational network and increasing awareness) dynamics which, when applied at an organisation level within ASOs, encourage successful and effective task-shifting. Related activities may be used to increase service quality and access for GBMSM. Considerations for application and management practice is provided.
Collapse
|
13
|
Thetsane RM, Mokhethi M, Ramathebane M, Leseba N. Utilisation of village health workers’ services for tuberculosis screening in Lesotho. S Afr Fam Pract (2004) 2022; 64:e1-e6. [PMID: 36226948 PMCID: PMC9575368 DOI: 10.4102/safp.v64i1.5581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 12/03/2022] Open
Abstract
Background Village health workers (VHWs) play an essential role because they extend the capacity of primary healthcare, particularly for developing countries. In Lesotho, VHWs are part of the primary healthcare connecting the community with clinics in their respective villages. They contribute to the prevention of the spread of tuberculosis (TB) within their catchment areas by encouraging communities to partake in TB screening. This study aimed at identifying factors associated with the utilisation of VHWs’ service to undertake TB screenings in Lesotho. Methods This study emanates from the main study that used a cross-sectional descriptive design. A total of 19 health service areas (HSAs) comprised 17 catchment areas and two clinics, each randomly selected from the District Health Management Team (DHMT) and the Lesotho Flying Doctors Service (LFDS), respectively. A total of 2928 individual household members aged 15 and above were included in the study. Data analysis included descriptive and inferential statistics. Results There were more female than male respondents, with a majority (77%) below 65 years of age. Tuberculosis knowledge of respondents was mostly on the TB symptoms and curability of TB, but they were less knowledgeable about the causes of TB. The use of VHWs’ services for TB screening was very low (23.3%). Conclusion The study revealed that while respondents were to some extent knowledgeable about TB, their utilisation of VHWs’ services for TB screening varied with education level, having worked in South Africa and the household size at α = 0.01.
Collapse
Affiliation(s)
- Regina M Thetsane
- Department of Business Administration, Faculty of Social Sciences, National University of Lesotho, Maseru.
| | | | | | | |
Collapse
|
14
|
Teshome DF, Balcha SA, Ayele TA, Atnafu A, Sisay M, Asfaw MG, Mitike G, Gelaye KA. Perceived barriers and enablers influencing health extension workers toward home-based hypertension screening in rural northwest Ethiopia: interpretive descriptive study. BMC Health Serv Res 2022; 22:1156. [PMID: 36100900 PMCID: PMC9472423 DOI: 10.1186/s12913-022-08523-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hypertension, a major but modifiable risk factor for cardiovascular diseases, is a global health problem including Ethiopia. In a limited infrastructure task sharing of hypertension screening for community health workers is a feasible strategy to improve hypertension management. Recent finding have shown that trained health extension workers (HEWs) can identify high blood pressure, which was effective and feasible. Identifying barriers and enablers for home-based hypertension screening by HEWs is crucial for its implementation. This study aimed to explore barriers and enablers that influence health extension workers' home-based hypertension screening in the community. METHODS The interpretive descriptive design was implemented. In-depth interviews were conducted during October, 2020. A total of 26 participants including HEWs, supervisors, and heads of district health office were purposively selected. They were asked to describe their perception toward home-based hypertension screening by the HEWs. The interviews were audio-recorded, transcribed verbatim into Amharic, and translated into English. The transcripts were coded and themes were identified. Thematic approach was used for data analysis. RESULTS The participants identified key perceived barriers and enablers of HEWs home-based hypertension screening. The most common barriers were a lack of hypertension training, blood pressure measuring devices, blood pressure guidelines and manuals, skilled HEWs, financial incentives, and poor community awareness of the disease. The most common enablers were support from community leaders, presence of functional development army and community trust for HEWs, presence of routine campaign on vaccination and community based health insurance, and an integrated health system. CONCLUSIONS Our findings have implications for the HEWs' ongoing implementation of home-based hypertension screening. Successful implementation of this strategy requires scaling up of hypertension training programs for health extension workers and their supervisors, provision of standardized protocols, provision of adequate blood pressure measuring equipment, and regular supportive supervision.
Collapse
Affiliation(s)
- Destaw Fetene Teshome
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Shitaye Alemu Balcha
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Awoke Ayele
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mekonnen Sisay
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Marye Getnet Asfaw
- Department of Emergency Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getnet Mitike
- International Institute for Primary Health Care-Ethiopia, Addis Ababa, Ethiopia
| | - Kassahun Alemu Gelaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
15
|
Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis. BMC Pregnancy Childbirth 2022; 22:674. [PMID: 36050632 PMCID: PMC9434878 DOI: 10.1186/s12884-022-04869-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. METHODS We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7-9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention's acceptability and feasibility, in terms of participants' views and the intervention aims. RESULTS We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members' negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. CONCLUSION Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.
Collapse
|
16
|
Kisigo GA, Mcharo OC, Robert JL, Peck RN, Sundararajan R, Okello ES. Understanding barriers and facilitators to clinic attendance and medication adherence among adults with hypertensive urgency in Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000919. [PMID: 36962785 PMCID: PMC10021323 DOI: 10.1371/journal.pgph.0000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022]
Abstract
Hypertensive urgency is a major risk factor for cardiovascular events and premature deaths. Lack of medication adherence is associated with poor health outcomes among patients with hypertensive urgency in resource-limited settings. To inform the development of tailored interventions to improve health outcomes in this population, this study aimed at understanding facilitators and barriers to clinic attendance and medication adherence among Tanzanian adults with hypertensive urgency. We conducted in-depth interviews with 38 purposively selected participants from three groups: 1) patients with hypertension attending hypertension clinic, 2) patients with hypertension not attending hypertension clinic, and 3) clinic health workers. Interviews were conducted using a semi-structured guide which included open-ended questions with prompts to encourage detailed responses. In their narrative, patients and healthcare workers discussed 21 types of barriers/facilitators to clinic attendance and medication adherence: 12 common to both behaviors (traditional medicine, knowledge and awareness, stigma, social support, insurance, reminder cues, symptoms, self-efficacy, peer support, specialized care, social services, religious beliefs); 6 distinct to clinic attendance (transport, clinic location, appointment, patient-provider interaction, service fragmentation, quality of care); and 3 distinct to medication adherence (drug stock, side effects, medicine beliefs). The majority of identified barriers/facilitators overlap between clinic attendance and medication adherence. The identified barriers may be surmountable using tailored supportive intervention approaches, such as peer counselors, to help patients overcome social challenges of clinic attendance and medication adherence.
Collapse
Affiliation(s)
- Godfrey A. Kisigo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Onike C. Mcharo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - John L. Robert
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Robert N. Peck
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Radhika Sundararajan
- Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Elialilia S. Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| |
Collapse
|
17
|
Manavalan P, Madut DB, Wanda L, Msasu A, Mmbaga BT, Thielman NM, Watt MH. A community health worker delivered intervention to address hypertension among adults engaged in HIV care in northern Tanzania: Outcomes from a pilot feasibility study. J Clin Hypertens (Greenwich) 2022; 24:1095-1104. [PMID: 35899325 PMCID: PMC9380132 DOI: 10.1111/jch.14518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/27/2022] [Accepted: 05/07/2022] [Indexed: 11/28/2022]
Abstract
Current care models are inadequate to address the dual epidemic of hypertension and HIV in sub‐Saharan Africa. We developed a community health worker (CHW)‐delivered educational intervention, integrated into existing HIV care to address hypertension in persons living with HIV. A detailed educational curriculum was created with five sessions: three in‐person clinic sessions and two telephone sessions. The intervention was piloted among hypertensive adults at one HIV clinic in northern Tanzania over a 4‐week period. Primary outcomes were feasibility, fidelity, and acceptability of the intervention. Secondary outcomes included hypertension care engagement and systolic and diastolic blood pressure (SBP and DBP). Among 16 eligible participants, 14 (64% women, median age of 54.5 years) were recruited into the study, and 13 (92.9%) completed all five intervention sessions. The intervention was delivered with 98.8% fidelity to the curriculum content. Hypertension care engagement improved following the intervention. At baseline, two (15.4%) participants had seen a doctor previously for hypertension, compared to 11 (84.6%) participants post‐intervention (P = .0027). No participant was using antihypertensives at baseline, compared to 10 (76.9%) post‐intervention (P = .0016). Pre‐intervention median SBP was 164 (IQR 152–170) mmHg, compared to post‐intervention SBP of 146 (IQR 134–154) mmHg (P = .0029). Pre‐intervention median DBP was 102 (IQR 86–109) mmHg, compared to post‐intervention DBP of 89 (IQR 86–98) mmHg (P = .0023). A CHW‐delivered educational intervention, integrated into existing HIV care, is feasible and holds promise in improving hypertension care engagement and reducing blood pressure. Further research is needed to evaluate the efficacy and scale‐up of our intervention.
Collapse
Affiliation(s)
- Preeti Manavalan
- Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida, USA.,Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Deng B Madut
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Lisa Wanda
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Ally Msasu
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Blandina T Mmbaga
- Duke Global Health Institute, Durham, North Carolina, USA.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan M Thielman
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Melissa H Watt
- Duke Global Health Institute, Durham, North Carolina, USA.,Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
18
|
Adam M, Job N, Mabaso B, Bärnighausen T, Kuhnert KL, Johnston J, Mqungwana N, Le Roux I, Mbewu N, Gates J, Scott K, Vandormael A, Greuel M, Prober C, McMahon SA. "The Videos Gave Weight to Our Work": Animated mHealth Videos and Tablet Technology Boost Community Health Workers' Perceived Credibility in Khayelitsha, South Africa. QUALITATIVE HEALTH RESEARCH 2022; 32:1273-1284. [PMID: 35674176 DOI: 10.1177/10497323221091504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Mobile health (mHealth) interventions are increasingly used to support community health workers (CHWs) in low-and middle-income countries. As near-peers within their communities, the credibility of CHWs is sometimes questioned-a recognized barrier to their efficacy. Nested within a large, randomized-controlled trial, this qualitative study captured the experiences of South African CHWs, called "Mentor-Mothers," using tablets and animated videos to promote exclusive breastfeeding. We conducted in-depth telephone interviews with 26 tablet-carrying Mentor-Mothers. We analyzed interview transcripts using a Grounded Theory approach, then developed a theoretical framework, based on an emerging theme, for understanding how tablet technology boosts the perceived credibility of CHWs. Tablet-carrying Mentor-Mothers described an increase in their perceived credibility, which they attributed to overt and signaling effects related to enhanced credibility of (1) their messages, (2) themselves as messengers, and (3) the program employing them. Mobile technology investments in CHWs could enhance their credibility, translating into meaningful investments in the health of under-served communities.
Collapse
Affiliation(s)
- Maya Adam
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Heidelberg University Institute of Global Health, Heidelberg, Germany
| | - Nophiwe Job
- Digital Medic South Africa, Cape Town, South Africa
| | - Bongekile Mabaso
- School of Management Studies, University of Cape Town, Cape Town, South Africa
| | - Till Bärnighausen
- Heidelberg University Institute of Global Health, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
- Wellcome Trust's Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | | | | | | | - Ingrid Le Roux
- The Philani Maternal Child Health and Nutrition Trust, Khayelitsha, South Africa
| | - Nokwanele Mbewu
- The Philani Maternal Child Health and Nutrition Trust, Khayelitsha, South Africa
| | - Jennifer Gates
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kerry Scott
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alain Vandormael
- Heidelberg University Institute of Global Health, Heidelberg, Germany
| | - Merlin Greuel
- Heidelberg University Institute of Global Health, Heidelberg, Germany
| | - Charles Prober
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Center for Health Education, Stanford, CA, USA
| | - Shannon A McMahon
- Heidelberg University Institute of Global Health, Heidelberg, Germany
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
19
|
Sorato MM, Davari M, Kebriaeezadeh A, Sarrafzadegan N, Shibru T. Antihypertensive prescribing pattern, prescriber adherence to ISH 2020 guidelines, and implication of outpatient drug price on blood pressure control at selected hospitals in Southern Ethiopia. Eur J Clin Pharmacol 2022; 78:1487-1502. [PMID: 35708747 DOI: 10.1007/s00228-022-03352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine the impact of drug prescribing pattern, outpatient drug price of medicines, and level of adherence to evidence-based international guidelines on blood pressure (BP) control at selected hospitals in Southern Ethiopia. METHODS Hospital-based cross-sectional study was conducted. The data entry and analysis were done by using SPSS version 21.0. RESULTS A mean age of participants was 55.87 ± 11.02 years. The rate of BP control was 17.5% based on International Society of Hypertension (ISH) guidelines 2020. In about two-thirds of patients, 270 (66.5%) were taking combination therapy. Mean annual cost of drugs for hypertension was 11.39 ± 3.98 US dollar (USD). Treatment was affordable for only 91 (22.4%) of patients. There was considerable variation on prescriber's adherence to evidence-based guidelines. Body mass index (BMI) of 18-24.9 kg/m2, adjusted odds ratio (AOR) = 3.63 (95% confidence interval (C.I), 1.169-11.251, p = 0.026), physically activity, AOR = 12.69 (95% C.I, 1.424-113.17, p = 0.023), presence of no comorbidity, AOR = 12.82 (95% C.I, 4.128-39.816, p = 0.000), and taking affordable antihypertensive regimen, AOR = 3.493 (95% C.I, 1.4242-9.826, p = 0.018), were positively associated BP control. CONCLUSION The level of BP control, affordability of drugs for the management of hypertension and related comorbidities, and the prescriber's adherence to evidence-based guidelines were inadequate. Therefore, addressing factors associated with good BP control including affordability and clinician adherence to evidence-based guidelines by responsible stakeholders could improve BP control and reduce associated complications.
Collapse
Affiliation(s)
- Mende Mensa Sorato
- Tehran University of Medical Sciences, Tehran, Iran. .,College of Medicine and Health Sciences, Department of Pharmacy, Arba Minch University, Arba Minch, Ethiopia.
| | - Majid Davari
- Faculty of Pharmacy, Department of Pharmacoeconomics and Pharmaceutical Administration, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Kebriaeezadeh
- Faculty of Pharmacy, Department of Pharmacoeconomics and Pharmaceutical Administration, Tehran University of Medical Sciences, Tehran, Iran
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Center, WHO Collaborating Center in EMR, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tamiru Shibru
- College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| |
Collapse
|
20
|
Tesema AG, Peiris D, Joshi R, Abimbola S, Fentaye FW, Teklu AM, Kinfu Y. Exploring complementary and competitive relations between non-communicable disease services and other health extension programme services in Ethiopia: a multilevel analysis. BMJ Glob Health 2022; 7:e009025. [PMID: 35738842 PMCID: PMC9226884 DOI: 10.1136/bmjgh-2022-009025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Ethiopia has recently revitalised its health extension programme (HEP) to address the rising burden of non-communicable diseases (NCDs). We examined the effects of existing essential HEP services on the uptake of NCD preventive services. METHODS We applied a mixed-effect non-linear model with a logit link function to identify factors associated with a community resident's probability of receiving NCD prevention services through the HEP. The data were drawn from the Ethiopian HEP assessment Survey conducted in all regions. The analysis included 9680 community residents, 261 health extension workers (HEWs), 153 health posts, 119 health centres, 55 districts and 9 regions, which we combined hierarchically into a single database. RESULTS In the 12 months before the survey, 22% of the sample population reported receiving NCD preventive service at least once. The probability of receiving NCD prevention service increased by up to 25% (OR=1.25, CI 1.01 to 1.53) if health centres routinely gathered NCD data from health posts and by up to 48% (OR=.48, CI 1.24 to 1.78) if they provided general (ie, non-NCD specific) training to HEWs. NCD preventive service uptake also increased if the HEW held level IV qualification (OR=1.32, CI 1.06 to 1.65) and lived in the community (OR=1.24, CI 1.03 to 1.49). Conversely, if facilities delayed general performance reviews of HEWs by a month, uptake of NCD prevention services decreased by 6% (OR=0.94, CI 0.91 to 0.97). We observed that better HIV/AIDS programme performance was associated with a lower uptake of NCD preventive services (OR=0.15, CI 0.03 to 0.85). CONCLUSION Despite efforts to improve NCD services through the HEP, the coverage remains limited. A strong HEP is good for the uptake of NCD preventive services. However, integration requires a careful balance, so that the success already recorded for some existing programmes is not lost.
Collapse
Affiliation(s)
- Azeb Gebresilassie Tesema
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - David Peiris
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Rohina Joshi
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, New Delhi, India
| | - Seye Abimbola
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Fasil Walelign Fentaye
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ), Ethiopia office, MERQ Consultancy PLC, Addis Ababa, Ethiopia
| | - Alula M Teklu
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ), Ethiopia office, MERQ Consultancy PLC, Addis Ababa, Ethiopia
| | - Yohannes Kinfu
- Department of Public Health, Faculty of Health, University of Canberra, Canberra, ACT, Australia
- Department of Health Science Metrics, University of Washington, Seattle, Washington, USA
| |
Collapse
|
21
|
Shayo EH, Kivuyo S, Seeley J, Bukenya D, Karoli P, Mfinanga SG, Jaffar S, Van Hout MC. The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania. BMC Health Serv Res 2022; 22:655. [PMID: 35578274 PMCID: PMC9112557 DOI: 10.1186/s12913-022-08065-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, the prevalence of non-communicable diseases (NCDs) has risen sharply amidst a high burden of communicable diseases. An integrated approach to HIV and NCD care offers the potential of strengthening disease control programmes. We used qualitative methods to explore patients' and care-providers' experiences and perspectives on the acceptability of integrated care for HIV-infection, diabetes mellitus (DM), and hypertension (HT) in Tanzania. METHODS A qualitative study was conducted in selected health facilities in Dar es Salaam and Coastal regions, which had started to provide integrated care and management for HIV, DM, and HT using a single research clinic for patients with one or more of these conditions. In-depth interviews were held with patients and healthcare providers at three time points: At enrolment (prior to the patient receiving integrated care, at the mid-line and at the study end). A minimum of 16 patients and 12 healthcare providers were sampled for each time point. Observation was also carried out in the respective clinics during pre- and mid-line phases. The Theoretical Framework of Acceptability (TFA) underpinned the structure and interpretation of the combined qualitative and observational data sets. RESULTS Patients and healthcare providers revealed a positive attitude towards the integrated care delivery model at the mid-line and at study end-time points. High acceptability was related to increased exposure to service integration in terms of satisfaction with the clinic setup, seating arrangements and the provision of medical care services. Satisfaction also centred on the patients' freedom to move from one service point to another, and to discuss the services and their own health status amongst themselves. Adherence to medication and scheduling of clinic appointments appeared central to the patient-provider relationship as an aspect in the provision of quality services. Multi-condition health education, patient time and cost-saving, and detection of undiagnosed disease conditions emerged as benefits. On the other hand, a few challenges included long waiting times and limited privacy in lower and periphery health facilities due to infrastructural limitations. CONCLUSION The study reveals a continued high level of acceptability of the integrated care model among study participants in Tanzania. This calls for evaluation in a larger and a comparative study. Nevertheless, much more concerted efforts are necessary to address structural challenges and maximise privacy and confidentiality.
Collapse
Affiliation(s)
- Elizabeth H. Shayo
- grid.416716.30000 0004 0367 5636National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Sokoine Kivuyo
- grid.416716.30000 0004 0367 5636National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Janet Seeley
- grid.415861.f0000 0004 1790 6116MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Dominic Bukenya
- grid.415861.f0000 0004 1790 6116MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Peter Karoli
- grid.416716.30000 0004 0367 5636National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Sayoki Godfrey Mfinanga
- grid.416716.30000 0004 0367 5636National Institute for Medical Research, Dar es Salaam, Tanzania
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine, Liverpool, UK
| | - Shabbar Jaffar
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine, Liverpool, UK
| | | |
Collapse
|
22
|
Blood Pressure and Blood Glucose Control and Associated Factors Among Adults with Hypertension at Three Public Hospitals in Southern Ethiopia. High Blood Press Cardiovasc Prev 2022; 29:287-304. [PMID: 35403966 DOI: 10.1007/s40292-022-00516-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/12/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION There is inadequate information on blood pressure (BP) and FBG (Blood pressure and Fasting blood glucose) control among adult hypertensive patients in Southern Ethiopia. AIM To determine the level and factors associated with poor BP and FBG control among adult hypertensive patients on regular follow-up at three public hospitals RESULTS: We included 406 adult hypertensives with mean age of 55.87 ± 11.03 years. Mean systolic BP was 134.46 ± 13.44 mmHg; and mean diastolic BP was 82.10 ± 9.44 mmHg. More than eight out of 205 (86.2%) of patients did not achieve BP and FBG target level. Having body mass index 18-24.9 kg/m2, Adjusted odds ratio (AOR) = 0.317 (95% C.I. for AOR, 0.135-0.740, p = 0.008); having no comorbidity, AOR = 0.425 (95% C.I. for AOR, 0.232-0.779, p = 0.006); physically activity, AOR = 0.303 (95% C.I., 0.110-0.829, p = 0.020); having low perceived health risk, AOR = 0.095 (95% C.I., 0.014-0.632, p = 0.015); taking monotherapy, AOR = 3.34 (95% C.I. for AOR, 1.121-10.524, p = 0.033); and history of hospitalization, AOR = 7.048 (95% C.I. for AOR, 2.486-19.954, p = 0.000) were associated with poor BP and FBG control. CONCLUSIONS The level of BP and FBG control was low. Improving screening of hypertensive patients for diabetes; addressing obesity and mental health; strengthening healthy life style interventions and enhancing appropriate dose intensification of prescribed anti-hypertensives by responsible bodies are critical to improve BP and FBG control.
Collapse
|
23
|
Khalid A, Adamjee R, Sattar S, Hoodbhoy Z. Maternal and child surveillance in peri-urban communities: Perceptions of women and community health workers from Pakistan. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000295. [PMID: 36962403 PMCID: PMC10021568 DOI: 10.1371/journal.pgph.0000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/02/2022] [Indexed: 06/18/2023]
Abstract
Community health workers (CHWs) in maternal, newborn, and child health (MNCH) programs play an important role in demographic surveillance activities; however, there is lack of literature regarding the community and CHWs' perceptions about these activities. The purpose of this study was to explore perceptions of married women of reproductive age (MWRA) regarding the role of CHWs involved in maternal and child surveillance and explore facilitators and barriers for CHWs involved in surveillance activities. A qualitative study was conducted in five peri-urban surveillance sites along the coastal belt of Bin Qasim Town, Karachi, Pakistan. In-depth interviews were conducted with 25 randomly selected MWRAs and 15 CHWs. A thematic analysis was performed to explore perceptions, barriers, and facilitators of the study participants about maternal and child surveillance activities. The results showed that MWRAs perceived surveillance CHWs as service providers with regards to standard counselling i.e. importance of antenatal care, nutrition, immunization, and distribution of iron and folic acid tablets to pregnant women, child growth assessment, and referral of sick children to the health facility. Trust in the CHWs was an enabler for MWRAs, whereas lack of incentives was cited as a barrier to share their health data. CHWs perceived themselves as a bridge in liaising community with the primary health care facility. They highlighted an enabling environment such as appreciation, supportive supervision, training, and utilization of digital data collection tools as facilitators for their work. Low health literacy of the communities, lack of provision of incentives by CHWs to the community, and facility-based experiences of the community were reported as barriers. Surveillance CHWs are an integral link between the health facility and MWRAs. Hence an enabling environment may lead to improved health service delivery, translating into meaningful impact for the mother and child.
Collapse
Affiliation(s)
- Ayesha Khalid
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Rehan Adamjee
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Saima Sattar
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Zahra Hoodbhoy
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| |
Collapse
|
24
|
Ngcobo S, Scheepers S, Mbatha N, Grobler E, Rossouw T. Roles, Barriers, and Recommendations for Community Health Workers Providing Community-Based HIV Care in Sub-Saharan Africa: A Review. AIDS Patient Care STDS 2022; 36:130-144. [PMID: 35438523 PMCID: PMC9057893 DOI: 10.1089/apc.2022.0020] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
While the impact of Community Health Workers (CHWs) on home-based human immunodeficiency virus (HIV) care has been documented, barriers and recommendations have not been systematically reviewed. Following the reporting requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used an aggregative narrative synthesis approach to summarize the results of qualitative studies published between January 1, 2000, and November 6, 2020 in the following databases: PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including education and health promotion; HIV-specific care (HIV testing services; screening for opportunistic infections and acute illness); medication delivery; tracing persons who had defaulted from care; and support (treatment support; referral; home-based care; and psychosocial support). Many different barriers to community-based HIV care were reported and centered on the following themes: Stigma and nondisclosure; inadequate support (lack of resources, inadequate training, inadequate funding, and inadequate monitoring); and health system challenges (patients' preference for more frequent visits and poor integration of CHWs in the wider health care system). Recommendations to mitigate these barriers included: addressing HIV-related stigma; introducing updated and relevant CHW training; strengthening the supervision of CHWs; coordinating care between the home and facilities; incorporating patient-centered mHealth approaches; and committing to the funding and resources needed for successful community-based care. In summary, CHWs are providing a variety of important community-based HIV services but face challenges with regards to training, resources, and supervision.
Collapse
Affiliation(s)
- Sanele Ngcobo
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
| | - Susan Scheepers
- Medical Library, University of Pretoria, Pretoria, South Africa
| | - Nothando Mbatha
- Department of Public Health and University of Pretoria, Pretoria, South Africa
| | - Estelle Grobler
- Medical Library, University of Pretoria, Pretoria, South Africa
| | - Theresa Rossouw
- Department of Immunology, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
25
|
Sondakh JJ, Warastuti W, Susatia B, Wildan M, Sunindya BR, Budiyanto MAK, Fauzi A. Indonesia medical students' knowledge, attitudes, and practices toward COVID-19. Heliyon 2022; 8:e08686. [PMID: 34977397 PMCID: PMC8711172 DOI: 10.1016/j.heliyon.2021.e08686] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 04/04/2021] [Accepted: 12/23/2021] [Indexed: 12/23/2022] Open
Abstract
Implementing health protocols and preventive measures are the only effective ways to suppress COVID-19 transmission before vaccines and antiviral drugs are developed. The implementation of health protocols and preventive measures are influenced by one's knowledge, attitudes, and practices (KAP) toward this pandemic. Medical students as candidates for healthcare workers and role models for the community should have a good KAP. This study intends 1) to explore the KAP of medical students in Indonesia toward COVID-19 and 2) to assess which demographic factors have a significant effect on their KAP scores. An online questionnaire consisting of 18 items of knowledge, six items of attitudes, and 12 items of practices were used as instruments in this study. After being distributed for two weeks in June 2020, 525 respondents whose data were worth analyzing were obtained. The respondents consisted of male and female students, from diploma to bachelor degree, and came from all four types of higher education institutions in Indonesia. The results, 48% of respondents had good knowledge, 81% had good attitudes, and 43.5% had good practices toward COVID-19. The location of students' residence has no significant effect on their KAP score. Gender has a significant effect on knowledge and practice scores. Age, institution type, and institution status have a significant effect on their three KAP domains. The KAP survey results can be used as a reflection of the importance of the curriculum that prepares medical students for the pandemic. Medical students are also expected to be able to actively participate in educating people around them on how to minimize the transmission of COVID-19 during the pandemic.
Collapse
Affiliation(s)
| | - Widya Warastuti
- Politeknik Kesehatan Kementerian Kesehatan Palangka Raya, Indonesia
| | - Budi Susatia
- Politeknik Kesehatan Kementerian Kesehatan Malang, Indonesia
| | - Moh. Wildan
- Politeknik Kesehatan Kementerian Kesehatan Malang, Indonesia
| | | | | | | |
Collapse
|
26
|
Njeru RW, Uddin MF, Zakayo SM, Sanga G, Charo A, Islam MA, Hossain MA, Kimani M, Mwadhi MK, Ogutu M, Chisti MJ, Ahmed T, Walson JL, Berkley JA, Jones C, Theobald S, Muraya K, Sarma H, Molyneux S. Strengthening the role of community health workers in supporting the recovery of ill, undernourished children post hospital discharge: qualitative insights from key stakeholders in Bangladesh and Kenya. BMC Health Serv Res 2021; 21:1234. [PMID: 34775968 PMCID: PMC8590969 DOI: 10.1186/s12913-021-07209-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 10/22/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Undernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines. The role of community health workers (CHWs) in supporting post-discharge recovery to improve outcomes has not been adequately explored. METHODS This paper draws on qualitative research conducted as part of the Childhood Acute Illnesses and Nutrition (CHAIN) Network in Bangladesh and Kenya. We interviewed family members of 64 acutely ill children admitted across four hospitals (a rural and urban hospital in each country). 27 children had severe wasting or kwashiorkor on admission. Family members were interviewed in their homes soon after discharge, and up to three further times over the following six to fourteen months. These data were supplemented by observations in facilities and homes, key informant interviews with CHWs and policy makers, and a review of relevant guidelines. RESULTS Guidelines suggest that CHWs could play a role in supporting recovery of undernourished children post-discharge, but the mechanisms to link CHWs into post-discharge support processes are not specified. Few families we interviewed reported any interactions with CHWs post-discharge, especially in Kenya, despite our data suggesting that opportunities for CHWs to assist families post-discharge include providing context sensitive information and education, identification of danger signs, and supporting linkages with community-based services and interventions. Although CHWs are generally present in communities, challenges they face in conducting their roles include unmanageable workloads, few incentives, lack of equipment and supplies and inadequate support from supervisors and some community members. CONCLUSION A multi-pronged approach before or on discharge is needed to strengthen linkages between CHWs and children vulnerable to poor outcomes, supported by clear guidance. To encourage scale-ability and cost-effectiveness of interventions, the most vulnerable, high-risk children, should be targeted, including undernourished children. Intervention designs must also take into account existing health worker shortages and training levels, including for CHWs, and how any new tasks or personnel are incorporated into hospital and broader health system hierarchies and systems. Any such interventions will need to be evaluated in carefully designed studies, including tracking for unintended consequences.
Collapse
Affiliation(s)
- Rita Wanjuki Njeru
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya.
| | - Md Fakhar Uddin
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
| | | | - Gladys Sanga
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - Anderson Charo
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - Md Aminul Islam
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
| | - Md Alamgir Hossain
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
| | - Mary Kimani
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - Mercy Kadzo Mwadhi
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - Michael Ogutu
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
| | - Judd L Walson
- Departments of Global Health, Medicine, Paediatrics and Epidemiology, University of Washington Seattle, Seattle, USA
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
| | - Caroline Jones
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical medicine, Liverpool, UK
| | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - Haribondhu Sarma
- Departments of Global Health, Medicine, Paediatrics and Epidemiology, University of Washington Seattle, Seattle, USA
- Research School of Population Health, The Australian National University, Canberra ACT, Canberra, 0200, Australia
| | - Sassy Molyneux
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya.
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK.
| |
Collapse
|
27
|
Abstract
Background: Village health workers (VHWs) can serve as a valuable resource to address public health needs in resource-limited settings such as Uganda. However, the successful implementation of VHW programs can be limited by poor acceptability among community members. Kisoro District Hospital (KDH) in Kisoro District, Uganda operates a VHW program and, at the time of the study, was expanding its services to 11 additional villages. Objective: The objective of this study was to evaluate community perceptions of VHWs in villages of Kisoro District with no prior exposure to the KDH VHW program in order to improve community acceptance when expanding the program to additional villages. Methods: We administered surveys to 658 community members from 11 villages to evaluate their perceptions of VHWs prior to receiving VHW services. Additionally, we conducted focus group discussions among 97 participants to explore perceptions of VHWs in further depth. Findings: Community members were generally accepting of VHWs. They preferred that VHWs provide both curative and preventive services across a broad range of health domains as opposed to a single disease. Expectations of the responsibilities of a VHW were influenced by agricultural occupational and household responsibilities, particularly for women. Participants expressed a preference to be actively involved in the selection and oversight of VHWs and that VHWs receive compensation. Conclusions: 1) Community members’ expectations of VHWs are shaped by environmental, cultural, and social factors. 2) Active community engagement in the VHW program is key. 3) Aligning a VHW program with community perceptions may improve acceptance, in turn influencing effectiveness and sustainability. These findings were used to expand the KDH VHW Program into the participating villages in a manner consistent with community preferences. Our findings may provide guidance on enhancing the uptake of community-based VHW programs for VHW stakeholders and policymakers in other settings.
Collapse
|
28
|
Ludwick T, Endrias M, Morgan A, Kane S, McPake B. Moving From Community-Based to Health-Centre Based Management: Impact on Urban Community Health Worker Performance in Ethiopia. Health Policy Plan 2021; 37:169-188. [PMID: 34519336 DOI: 10.1093/heapol/czab112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
Abstract
Community health worker (CHW) performance is influenced by the way in which management arrangements are configured vis-a-vis the community and health services. While low/middle-income contexts are changing, the literature provides few examples of country efforts to strategically modify management arrangements to support evolving CHW roles (e.g. chronic disease care) and operating environments (e.g. urbanization). This paper aims to understand the performance implications of changing from community-based to health centre-based management, on Ethiopia's Urban Health Extension Professionals (UHEPs), and the tensions/trade-offs associated with the respective arrangements. We conducted semi-structured interviews/focus groups to gather perspectives and preferences from those involved with the transition (13 managers/administrators, 5 facility-based health workers, 20 UHEPs). Using qualitative content analysis, we deductively coded data to four program elements impacted by changed management arrangements and known to affect CHW performance (work scope; community legitimacy; supervision/oversight/ownership; facility linkages) and inductively identified tensions/trade-offs. Community-based management was associated with wider work scope, stronger ownership/regular monitoring, weak technical support, and weak health center linkages, with opposite patterns observed for health center-led management. Practical trade-offs included: heavy UHEP involvement in political/administrative activities under Kebele-based management; resistance to working with UHEPs by facility-based workers; and, health centre capacity constraints in managing UHEPs. Whereas the Ministry of Health/UHEPs favoured health centre-led management to capitalize on UHEPs' technical skills, Kebele officials were vested in managing UHEPs and argued for community interests over UHEPs' professional interests; health facility managers/administrators held divided opinions. Management arrangements influence the nature of CHW contributions towards the achievement of health, development, and political goals. Decisions about appropriate management arrangements should align with the nature of CHW roles and consider implementation setting, including urbanization, political decentralization, and relative capacity of managing institutions.
Collapse
Affiliation(s)
- Teralynn Ludwick
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, 333 Exhibition Street, Carlton, Victoria, Australia
| | - Misganu Endrias
- Health Research and Technology Transfer Office, SNNPR Regional Health Bureau, Hawassa, Ethiopia
| | - Alison Morgan
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Global Financing Facility, The World Bank Group, Washington, DC, USA
| | - Sumit Kane
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Barbara McPake
- Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| |
Collapse
|
29
|
Sohail S, Wajid G, Chaudhry S. Perceptions of Lady Health Workers and their trainers about their curriculum for implementing the interventions identified for Essential Package of Health Services for Pakistan. Pak J Med Sci 2021; 37:1295-1301. [PMID: 34475901 PMCID: PMC8377911 DOI: 10.12669/pjms.37.5.4175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/26/2021] [Accepted: 05/15/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives Lady Health Workers (LHWs) form the central cadre of community-based health workers in Pakistan. They must be trained well for implementing community-based interventions identified for Essential Package of Health Services (EPHS) by the government of Pakistan. This study aims to explore the perceptions of LHWs and their trainers about their existing curriculum and identifies gaps in the curriculum for effective implementation of the interventions identified in EPHS. Methods In this qualitative study, perceptions of 45 LHWs were taken through focus group discussions and their six trainers were interviewed as well. In addition, three experts analyzed the LHWs training curriculum to identify its relevance with achieving the community-based interventions as described in the EPHS by the government of Pakistan. Results Thematic analysis of the information gathered by the interviews of trainers and focus group discussions from LHWs, was performed. Most participants were satisfied with their curriculum but suggested the addition of topics on emerging health issues, neonatal resuscitation, mental health and rehabilitation. Participants felt a deficiency in practical skills, communication skills and leadership skills. Experts identified gap in the current LHWs curriculum to address the recently identified community-based interventions. Conclusions The current curriculum of LHWs need reforms to make it compatible with Essential Package of Health Services for Pakistan. The suggested areas for improvement include knowledge of emerging health issues, neonatal resuscitation, adolescent problems, mental health and rehabilitative services.
Collapse
Affiliation(s)
- Shaherzad Sohail
- Dr. Shaherzad Sohail, MBBS, MCPS, FCPS, MHPE Associate Professor, Gynae/Obs Shalamar medical and Dental College, Lahore, Pakistan
| | - Gohar Wajid
- Dr. Gohar Wajid, MBBS, MSC, MPH, PhD Med Education Technical officer, Health Professions Education World Health Organization Cairo, Egypt
| | - Saima Chaudhry
- Dr. Saima Chaudhry, BDS, MME Officiating Head of Department University of Health Sciences, Lahore, Pakistan
| |
Collapse
|
30
|
Tumuhimbise W, Musiimenta A. A review of mobile health interventions for public private mix in tuberculosis care. Internet Interv 2021; 25:100417. [PMID: 34401376 PMCID: PMC8350595 DOI: 10.1016/j.invent.2021.100417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/04/2021] [Accepted: 06/11/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends the use of mobile health (mHealth) technologies as emerging opportunities to closing the gaps in Tuberculosis (TB) care through enhancing Public Private Mix (PPM). However, little is known about mHealth interventions that have been used for enhancing PPM in TB care, those that worked and those that did not. OBJECTIVE This review summarizes the published evidence on the utilization and effectiveness of mHealth interventions for public private mix in TB care from literature. METHODS Google scholar, PUBMED, IEEE Xplore and ScienceDirect databases were searched for peer reviewed literature from 1st January 2003 to 31st December 2020 for studies about the mHealth interventions for public private mix in TB care. This was guided by the scoping review methodology proposed by Arksey and O' Malley. In order to assess the quality of the selected studies, mHealth evidence reporting and assessment (mERA) checklist was utilized. Studies that discussed the utilization of mHealth interventions for implementing PPM in TB care were included. Nine studies met the inclusion criteria and were analyzed for review. RESULTS The review found out the application of mHealth in Public Private Mix in TB care through the following ways; 1) TB screening, 2) TB case notification 3) TB treatment adherence 4) data collection and management 5) patient referral and follow up, and 6) education. This resulted into high user experience, significant time reduction in data aggregation, increased case notification and referrals and proactive tracking and provision of follow up care hence reduced treatment and completion gaps. One study yielded suboptimal utilization due to the technical and operational challenges encountered by the healthcare workers. CONCLUSION Although this scoping review highlights the role of mHealth technologies in enhancing PPM in TB care, its utilization is still limited in African settings. No Africa-based study was identified by this review. Future studies should focus on assessing the utilization of mHealth for PPM in Africa.
Collapse
Affiliation(s)
| | - Angella Musiimenta
- Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| |
Collapse
|
31
|
Chowdhury R, McKague K, Krause H. How workers respond to social rewards: evidence from community health workers in Uganda. Health Policy Plan 2021; 36:239-248. [PMID: 33881139 PMCID: PMC8058949 DOI: 10.1093/heapol/czaa162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 11/14/2022] Open
Abstract
This paper investigates the effect of a non-financial incentive-a competitive annual award-on community health workers' (CHWs) performance, an issue in the public health literature that has not been explored to its potential. Combining data on a competitive social 'Best CHW' award with the monthly performance of 4050 CHWs across Uganda, we examined if introducing social recognition awards improved the performance of CHWs. In contrast to predominant explanations about the effect of awards on motivation, our first multilevel mixed-effect models found that an award within a branch (consisting of ∼30 CHWs) was negatively associated with the performance of the local peers of the winning CHW. Models focused on non-winning branch offices revealed two additional findings. First, a branch showed underperformance if a CHW from any of the three neighbouring branches won an award in the previous year, with average monthly performance scores dropping by 27 percentage points. Second, this negative association was seen only in the top 50th percentile of CHWs. The bottom 50th percentile of CHWs exhibited increased performance by 13 percentage points. These counter-intuitive results suggest that the negative response from high performers might be explained by their frustration of not winning the award or by emotions such as envy and jealousy generated by negative social comparisons. Our results suggest that more fine-grained examination of data pertaining to motivators for CHWs in low-income countries is needed. Motivational incentives like awards may need to be customized for higher- and lower-performing CHWs.
Collapse
Affiliation(s)
- Reajul Chowdhury
- Corresponding author. Agriculture and Consumer Economics, University of Illinois, Urbana – Champaign, 59 Mumford Hall, 1301 W. Gregory Drive Urbana, IL 61801, USA. E-mail:
| | - Kevin McKague
- Shannon School of Business, Cape Breton University, Sydney, Nova Scotia B1M 1A2, Canada
| | - Heather Krause
- Principal Data Scientist, Datassist, Toronto, ON M4Y 3E1, Canada
| |
Collapse
|
32
|
Batte C, Mukisa J, Rykiel N, Mukunya D, Checkley W, Knauf F, Kalyesubula R, Siddharthan T. Acceptability of patient-centered hypertension education delivered by community health workers among people living with HIV/AIDS in rural Uganda. BMC Public Health 2021; 21:1343. [PMID: 34233648 PMCID: PMC8264981 DOI: 10.1186/s12889-021-11411-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 06/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background The prevalence of hypertension is increasing among people living with HIV/AIDS (PLWHA) in low- and middle-income countries (LMICs). However, knowledge of the complications and management of hypertension among PLWHA in Uganda remains low. We explored the acceptability of implementing hypertension (HTN) specific health education by community health workers (CHWs) among PLWHA in rural Uganda. Methods We conducted a qualitative study consisting of 22 in-depth interviews (14 PLWHA/HTN and 8 CHWs), 3 focus group discussions (FGDs), 2 with PLWHA/HTN and 1 with CHWs from Nakaseke district, Uganda. Participants were interviewed after a single session interaction with the CHW. Data were transcribed from luganda (local language) into English and analyzed using thematic analysis. We used Sekhon’s model of acceptability of health Interventions to explore participants’ perceptions. Results Participants believed CHWs utilized easy-to-understand, colloquial, non-technical language during education delivery, had a pre-existing rapport with the CHWs that aided faster communication, and had more time to explain illness than medical doctors had. Participants found the educational material (PocketDoktor™) to be simple and easy to understand, and perceived that the education would lead to improved health outcomes. Participants stated their health was a priority and sought further disease-specific information. We also found that CHWs were highly motivated to carry out the patient-centered education. While delivering the education, CHWs experienced difficulties in keeping up with the technical details regarding hypertension in the PocketDoktor™, financial stress and patient questions beyond their self-perceived skill level and experience. PLWHA/HTN had challenges accessing the health facility where the intervention was delivered and preferred a household setting. Conclusions Hypertension patient-centered education delivered by CHWs using the PocketDoktor™ was acceptable to PLWHA and hypertension in Nakaseke area in rural, Uganda. There is need for further studies to determine the cost implications of delivering this intervention among PLWHA across LMIC settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11411-6.
Collapse
Affiliation(s)
- Charles Batte
- School of Medicine, Lung Institute, Makerere University College of Health Sciences, Upper Hill Mulago Hill, Kampala, Uganda.
| | - John Mukisa
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Natalie Rykiel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - David Mukunya
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Kalyesubula
- School of Medicine, Lung Institute, Makerere University College of Health Sciences, Upper Hill Mulago Hill, Kampala, Uganda
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.,Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| |
Collapse
|
33
|
Gatuguta A, Colombini M, Seeley J, Soremekun S, Devries K. Supporting children and adolescents who have experienced sexual abuse to access services: Community health workers' experiences in Kenya. CHILD ABUSE & NEGLECT 2021; 116:104244. [PMID: 31882066 DOI: 10.1016/j.chiabu.2019.104244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/10/2019] [Accepted: 10/18/2019] [Indexed: 06/10/2023]
Abstract
UNLABELLED Child sexual abuse (CSA) is a global health problem with significant health consequences. The World Health Organization recommends immediate and long-term treatment for all survivors. However, in low- and middle-income countries, less than 10 % of sexually abused children seek health services. Community health workers (CHWs) can potentially increase uptake of services, but, the risks and benefits of services provided by CHWs are poorly understood. METHODS Through in-depth interviews, we examined the experiences of CHWs providing services to children in Kenya. Sixteen CHWs were purposively selected from two locations. Data were audio-recorded, transcribed verbatim and analysed thematically. FINDINGS Nearly all the CHWs reported assisting children who had experienced sexual abuse. Children were brought to their attention by caregivers, neighbours, teachers, local authorities or the police. CHWs roles included providing information and advice, assisting the child to report to the police, access healthcare or find shelter. Multiple challenges were reported including lack of support from formal institutions; community norms; safety concerns; inadequate resources and interference from family, perpetrators and local authorities. Lack of protocols and training on how to handle children was evident. CONCLUSIONS CHWs are a crucial community-level resource for CSA survivors and their caregivers. However, community norms, lack of guidelines and training may compromise the quality of services provided. There is a significant gap in literature on service models for CHWs delivering CSA services. Data are lacking on what services CHWs can effectively offer, how they should be delivered and what factors may influence delivery, acceptance and uptake of services.
Collapse
Affiliation(s)
- Anne Gatuguta
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Department of Community Health, School of Public Health, Kenyatta University, Nairobi, Kenya.
| | - Manuela Colombini
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Janet Seeley
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Seyi Soremekun
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Karen Devries
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| |
Collapse
|
34
|
Lederle M, Tempes J, Bitzer EM. Application of Andersen's behavioural model of health services use: a scoping review with a focus on qualitative health services research. BMJ Open 2021; 11:e045018. [PMID: 33952550 PMCID: PMC8103375 DOI: 10.1136/bmjopen-2020-045018] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Qualitative methods have become integral in health services research, and Andersen's behavioural model of health services use (BMHSU) is one of the most commonly employed models of health service utilisation. The model focuses on three core factors to explain healthcare utilisation: predisposing, enabling and need factors. A recent overview of the application of the BMHSU is lacking, particularly regarding its application in qualitative research. Therefore, we provide (1) a descriptive overview of the application of the BMHSU in health services research in general and (2) a qualitative synthesis on the (un)suitability of the model in qualitative health services research. METHODS We searched five databases from March to April 2019, and in April 2020. For inclusion, each study had to focus on individuals ≥18 years of age and to cite the BMHSU, a modified version of the model, or the three core factors that constitute the model, regardless of study design, or publication type. We used MS Excel to perform descriptive statistics, and applied MAXQDA 2020 as part of a qualitative content analysis. RESULTS From a total of 6319 results, we identified 1879 publications dealing with the BMSHU. The main methodological approach was quantitative (89%). More than half of the studies are based on the BMHSU from 1995. 77 studies employed a qualitative design, the BMHSU was applied to justify the theoretical background (62%), structure the data collection (40%) and perform data coding (78%). Various publications highlight the usefulness of the BMHSU for qualitative data, while others criticise the model for several reasons (eg, its lack of cultural or psychosocial factors). CONCLUSIONS The application of different and older models of healthcare utilisation hinders comparative health services research. Future research should consider quantitative or qualitative study designs and account for the most current and comprehensive model of the BMHSU.
Collapse
Affiliation(s)
- Mareike Lederle
- Public Health and Health Education, Pädagogische Hochschule Freiburg, Freiburg im Breisgau, Germany
| | - Jana Tempes
- Public Health and Health Education, Pädagogische Hochschule Freiburg, Freiburg im Breisgau, Germany
| | - Eva M Bitzer
- Public Health and Health Education, Pädagogische Hochschule Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
35
|
Reynolds EC, Onyango D, Mwando R, Oele E, Misore T, Agaya J, Otieno P, Tippett Barr BA, Lee GO, Akelo V. Mothers' Perspectives of Complementary Feeding Practices in an Urban Informal Settlement in Kisumu County, Western Kenya. Curr Dev Nutr 2021; 5:nzab065. [PMID: 34095736 PMCID: PMC8171250 DOI: 10.1093/cdn/nzab065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In informal settlements, the benefits of urban dwelling are diminished by conditions of poverty that exacerbate child undernutrition. The Child Health and Mortality Prevention Surveillance (CHAMPS) project has identified malnutrition as the leading underlying cause of death in children under 5 in the Manyatta urban informal settlement in Kisumu County, Kenya. OBJECTIVE This qualitative study, nested within the CHAMPS project, aimed to understand community perspectives on complementary feeding practices in this settlement. METHODS In-depth interviews were conducted with 20 mothers who lived in the urban informal settlement and had a child 6-23 months old. Two focus group discussions were conducted, 1 with mothers and 1 with community health workers (CHWs), to further explore themes related to complementary feeding. RESULTS Mothers were knowledgeable about globally recommended feeding practices, but such practices were often not implemented due to 1) the community/household water and sanitation environment, 2) the community/household food environment, 3) a lack of income and employment opportunities for women, and 4) sociocultural factors. Together, these create an environment that is not conducive to optimal child feeding practices. CONCLUSIONS To improve complementary feeding practices and child nutritional outcomes in Kenya's informal urban settings, both community- and individual-level factors should be addressed. Possible interventions include investment in water infrastructure and social protection programs, such as cash transfers.
Collapse
Affiliation(s)
- Elise C Reynolds
- University of Michigan School of Public Health, Ann Arbor,
MI, USA
- University of California, Davis, Davis, CA, USA
| | | | - Rael Mwando
- Kisumu County Department of Health, Kisumu, Kenya
| | | | | | - Janet Agaya
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Beth A Tippett Barr
- US Centers for Disease Control and Prevention–Kenya, Kisumu and
Nairobi , Kenya
| | - Gwenyth O Lee
- University of Michigan School of Public Health, Ann Arbor,
MI, USA
| | - Victor Akelo
- US Centers for Disease Control and Prevention–Kenya, Kisumu and
Nairobi , Kenya
| |
Collapse
|
36
|
Galvez A, Waite J, Jureidini K, Nesbit KC. Integrated care by community health workers in Malawi: Rehabilitation and blood pressure monitoring. AIMS Public Health 2021; 8:110-123. [PMID: 33575411 PMCID: PMC7870379 DOI: 10.3934/publichealth.2021009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/26/2021] [Indexed: 11/18/2022] Open
Abstract
Background Community health workers (CHWs) are essential providers of integrated care for people in low-resourced settings with a high burden from noncommunicable diseases (NCDs). Aims The purpose of this study was to evaluate a CHW training program in rural Malawi integrating blood pressure (BP) monitoring into rehabilitation care. Methods This was a retrospective cross-sectional study. The participants were a convenience sample of home-based palliative care CHWs at the local hospital (n = 59). Data collected included: a written pre- and post-knowledge test, skills competency checklist and a post-training program survey. Descriptive frequencies and paired t-tests (a = 0.05) were used for quantitative analyses. Themes in narrative responses in the post-training survey were analyzed qualitatively. Results Participant knowledge regarding BP monitoring procedures improved significantly on the post-test (M = 8.24, SD = 1.654) compared to the pre-test (M = 6.59, SD = 1.683), Z (49) = −5.569, p < 0.001. The pre-and post-tests were scored 0–10 points. All participants demonstrated competency in 100% of the skills. Participants reported the lack of transportation, teamwork and resources as barriers to their work. They reported trainings and opportunities to collaborate as facilitators to their work. Discussion This study demonstrated the effectiveness of a training program for CHWs which integrated BP monitoring with rehabilitation care for people with NCDs. This retention of knowledge and application to clinical practice serve as strong indicators of the feasibility and sustainability of the CHW training and care delivery program in resource-limited settings. Conclusion Our findings help demonstrate that training CHWs can be an effective way to help bridge the gap in health care access for people with disabilities in resource-limited countries.
Collapse
Affiliation(s)
| | - Jordan Waite
- Orthopedic and Neurological Rehabilitation, Los Gatos, CA, USA
| | | | - Kathryn C Nesbit
- UCSF/SFSU Graduate Program in Physical Therapy, San Francisco, CA, USA
| |
Collapse
|
37
|
Laurenzi CA, Skeen S, Coetzee BJ, Notholi V, Gordon S, Chademana E, Bishop J, Tomlinson M. Instructive roles and supportive relationships: client perspectives of their engagement with community health workers in a rural south African home visiting program. Int J Equity Health 2021; 20:32. [PMID: 33436011 PMCID: PMC7805205 DOI: 10.1186/s12939-020-01377-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/28/2020] [Indexed: 11/12/2022] Open
Abstract
Background Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa. Methods We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February–March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients’ home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed. Results We found that clients’ home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother’s advice. Conclusions These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients’ voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-020-01377-z.
Collapse
Affiliation(s)
- Christina A Laurenzi
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa. .,Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
| | - Sarah Skeen
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Bronwynè J Coetzee
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Vuyolwethu Notholi
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Sarah Gordon
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Emma Chademana
- One to One Africa Children's Fund, Cape Town, South Africa
| | - Julia Bishop
- One to One Africa Children's Fund, Cape Town, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa.,School of Nursing and Midwifery, Queens University Belfast, Belfast, UK
| |
Collapse
|
38
|
Hauc SC, Tshering D, Feliciano J, Atayde AMP, Aboukhater LM, Dorjee K, Dukpa T, Rinchen P, Yoezer N, Luc CM, Adhikari RN, Lhamo K, Khoshnood K. A Cross-Sectional Survey Analyzing Community Perception and Utilization of Village Health Workers Stratified by the Urban-Rural Divide Within the Kingdom of Bhutan. Asia Pac J Public Health 2020; 33:113-116. [PMID: 33174437 DOI: 10.1177/1010539520969232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Village health workers (VHWs) serve as an integral health resource for many resource limited nations, including the Kingdom of Bhutan. As such, we aimed to identify community perceptions as well as utilization rates and types with relation to VHWs based on the urban-rural divide. Our team conducted a randomized survey of 429 community members in 14 villages within the Western region of Bhutan. Our findings indicate VHWs in rural communities are requested for their services twice as much as their urban counterparts. More specifically, urban VHWs are utilized 2.5 times more for general community services, while rural VHWs are utilized more for accessing medications. Additionally, our research indicates a need to increase training of VHWs as well as overall program promotion relating to the specific services that VHWs can provide. These investigations indicate the importance of differentially allocating resources, programming, and training based on the urban-rural divide.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Tshering Dukpa
- Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
| | - Pema Rinchen
- Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
| | - Neema Yoezer
- Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
| | | | | | | | | |
Collapse
|
39
|
Al-Mujtaba M, Shobo O, Oyebola BC, Ohemu BO, Omale I, Shuaibu A, Anyanti J. Assessing the acceptability of village health workers' roles in improving maternal health care in Gombe State, Nigeria a qualitative exploration from women beneficiaries. PLoS One 2020; 15:e0240798. [PMID: 33091072 PMCID: PMC7580965 DOI: 10.1371/journal.pone.0240798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/03/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Maternal, and under-five mortality rates in Gombe State are disproportionately high. The Society for Family Health (a Non-Governmental Organization) in collaboration with Gombe State Primary Health Care Development Agency implemented the Village Health Worker (VHW) Program in Gombe to address the low uptakes of maternal neonatal and child health (MNCH) services and reduced the impact of healthcare worker insufficiency. VHWs are lay indigenous women trained to educate and encourage women to use MNCH services, provide simple community-based maternal and new-born care through home visits, and facilitate facility linkage. We assessed the acceptability of VHW services among women beneficiaries of the Program. Methods Qualitative data were obtained through six focus group discussions with 58 women beneficiaries of the VHW program who delivered within the last 12 months preceding study period (October–November 2018). Themes explored were roles and acceptability of VHWs, and the influence of VHWs on the uptake of MNCH services. We analyzed data with NVivo 12, using Grounded Theory. Results Participants’ mean age was 25.1 (± 5.3) years old. Most participants 39 (67%), had been in contact with a VHW for at least 10 months. VHWs visited pregnant women at home and registered them for antenatal care, provided them basic maternal healthcare, health education, and facilitated facility linkage. Participants generally accepted the VHW Program because it was community-based, VHWs were indigenous community members, delivered clear messages, and influenced husbands and mothers-in-law to support women’s’ use of MNCH services. VHWs’ interventions were perceived to have improved health literacy and the uptake of MNCH services. Participants generally admired the VHW occupation and recommended VHW program scale-up, and for VHWs to be offered basic obstetric training and employment by health facilities or the government. Conclusion The general acceptance and positive views of VHWs from beneficiaries of the program demonstrates the feasibility of the program to improve the uptake of MNCH services.
Collapse
Affiliation(s)
- Maryam Al-Mujtaba
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Federal Capital Territory, Nigeria
- * E-mail: ,
| | - Olukolade Shobo
- Monitoring and Evaluation Department, Society for Family Health, Abuja, Federal Capital Territory Nigeria
| | - Bolanle C. Oyebola
- Programmes Department, Society for Family Health, Abuja, Federal Capital Territory, Nigeria
| | - Benson O. Ohemu
- Communications Department, Society for Family Health, Abuja, Federal Capital Territory, Nigeria
| | - Isaac Omale
- Monitoring and Evaluation Department, Society for Family Health, Abuja, Federal Capital Territory Nigeria
| | - Abdulrahman Shuaibu
- Office of the Executive Secretary, Gombe State Primary Healthcare Development Agency, Gombe, Gombe State, Nigeria
| | - Jennifer Anyanti
- Office of the Deputy Managing Director, Society for Family Health, Abuja, Nigeria
| |
Collapse
|
40
|
Macharia LW, Wexler C, Brown M, Maloba M, Pricilla RA, Mabachi NM, Muchoki E, Babu S, Ochieng M, Gautney B, Goggin K, Finocchario-Kessler S. Implementation planning for community-based point-of-care HIV testing for infants: Recommendations from community leaders in Kenya. PLoS One 2020; 15:e0240476. [PMID: 33057444 PMCID: PMC7561120 DOI: 10.1371/journal.pone.0240476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/25/2020] [Indexed: 11/18/2022] Open
Abstract
Background Early infant diagnosis (EID) establishes the presence of HIV infection in HIV-exposed infants and children younger than 18 months of age. EID services are hospital-based, and thus fail to capture HIV-exposed infants who are not brought to the hospital for care. Point-of-care (POC) diagnostic systems deployed in the community could increase the proportion tested and linked to treatment, but little feasibility and acceptability data is available. Methods Semi-structured interviews (n = 74) were conducted by a Kenyan team with community members (Community Health Workers/Volunteers [CHW/CHV], Traditional Birth Attendants [TBAs], community leaders) and parents of HIV-exposed infants at four study sites in Kenya to elicit feedback on the acceptability and feasibility of community-based POC HIV testing. Results Participants described existing community health resources that could be leveraged to support integration of community-based POC HIV testing; however, the added demand placed on CHW/CHV could pose a challenge. Participants indicated that other potential barriers (concerns about confidentiality, disclosure, and HIV stigma) could be overcome with strong engagement from trusted community leaders and health providers, community sensitization, and strategic location and timing of testing. These steps were seen to improve acceptability and maximize the recognized benefits (rapid results, improved reach) of community-based testing. Conclusion Community members felt that with strategic planning and engagement, community-based POC HIV testing could be a feasible and acceptable strategy to overcome the existing barriers of hospital-based EID.
Collapse
Affiliation(s)
- Lynton W. Macharia
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | | | - Natabhona M. Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | | | | | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | - Kathy Goggin
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City, MO, United States of America
- Schools of Medicine and Pharmacy, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
- * E-mail:
| |
Collapse
|
41
|
Khumalo GE, Lutge E, Naidoo P, Mashamba-Thompson TP. Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis protocol. BMJ Open 2020; 10:e037876. [PMID: 33040005 PMCID: PMC7552870 DOI: 10.1136/bmjopen-2020-037876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In sub-Saharan Africa (SSA), Human Immunodeficiency Virus (HIV) is the leading cause of morbidity and mortality. Community healthcare workers (CHWs) worldwide have been reported to be effective in strengthening the HIV programme by providing services such as adherence support, HIV education and safe sex education as part of their roles. The main aim of this meta-synthesis is to synthesise qualitative evidence on studies that have been conducted in SSA countries to understand the barriers to and facilitators of providing HIV services by CHWs across all settings METHODS AND ANALYSIS: This meta-synthesis will be guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An initial search was conducted on 15 November 2019 for studies published between 2009 and 2019 using the population exposure outcome nomenclature. We searched the EBSCOHost- (ERIC; Health Source-Nursing/Academic Edition), Google Scholar and PubMed databases for the relevant studies. The Ritchie and Spencer framework will be used for data synthesis and the Supporting the Use of Research Evidence Framework analysis will be used to analyse data. We will conduct critical appraisal on selected studies using the Qualitative Assessment and Review Instrument to limit risk of bias. ETHICS AND DISSEMINATION This review does not involve any human participants and therefore ethical approval will not be required. We will publish the protocol as well as the findings in any relevant journal and various media namely conferences; symposia, local and international health stakeholders. PROSPERO REGISTRATION NUMBER CRD42020160012. CONCLUSION Evidence from this review will provide synthesised evidence to the utilisation of CHWs in HIV services in SSA.
Collapse
Affiliation(s)
- Gugulethu Eve Khumalo
- Discipline of Public Health Medicine, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
- Department of Health, KwaZulu-Natal, Pietermaritzburg, KwaZulu-Natal, South Africa
| | - Elizabeth Lutge
- KwaZulu Natal Department of Health, South African Government, Durban, KwaZulu Natal, South Africa
| | - Praba Naidoo
- Library, University of KwaZulu-Natal - Medical School, Durban, South Africa
| | | |
Collapse
|
42
|
|
43
|
Musoke D, Ssemugabo C, Ndejjo R, Molyneux S, Ekirapa-Kiracho E. Ethical practice in my work: community health workers' perspectives using photovoice in Wakiso district, Uganda. BMC Med Ethics 2020; 21:68. [PMID: 32746819 PMCID: PMC7397610 DOI: 10.1186/s12910-020-00505-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 07/16/2020] [Indexed: 12/04/2022] Open
Abstract
Background Health service delivery should ensure ethical principles are observed at all levels of healthcare. Working towards this goal requires understanding the ethics-related priorities and concerns in the day-to-day activities among different health practitioners. These practitioners include community health workers (CHWs) who are involved in healthcare delivery in communities in many low-and middle-income countries such as Uganda. In this study, we used photovoice, an innovative community based participatory research method that uses photography, to examine CHWs' perspectives on ethical concerns in their work. Methods We explored perspectives of 10 CHWs (5 females and 5 males) on ethical dimensions of their work for 5 months using photovoice in a rural community in Wakiso district, Uganda. As part of the study, we: 1. Oriented CHWs on photovoice research and ethics; 2. Asked CHWs to take photographs of key ethical dimensions of their work; 3. Held monthly meetings to discuss and reflect on the photos; and 4. Disseminated the findings. The discussions from the monthly meetings were audio recorded, transcribed, and emerging data analysed using conventional content analysis with the help of Atlas ti version 6.0.15. Results CHWs were aware of and highly concerned about the need to observe ethical principles while carrying out their roles. The ethical principles CHWs were aware of and endeavoured to observe during their work were: maintaining professional integrity and abiding by ethical principles of practice; ethical responsibility in patient care; maintaining confidentiality while handling clients; respect for persons and communities; and enhancing their knowledge and skills for better practice. However, CHWs also identified challenges concerning their observance of ethical principles including: low commitment to their work due to other obligations; availability of some reference materials and guidelines in English yet majority could only read in the local language; and minimal avenues for knowledge enhancement such as trainings. Conclusions CHWs were aware of and keen to discuss ethical issues in their work. However, there is need to address the challenges they face so as to facilitate observing ethical principles during the course of their work in communities.
Collapse
Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Charles Ssemugabo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sassy Molyneux
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elizabeth Ekirapa-Kiracho
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
44
|
Cardoso GCP, Santos EMD, Alemayehu YK, Woldemichael K, Ereso BM, Lemma W. Sítios simbólicos de pertencimento e prevenção e controle da tuberculose: percepções e práticas dos Agentes Comunitários de Saúde no Brasil e na Etiópia. CIENCIA & SAUDE COLETIVA 2020; 25:2927-2937. [DOI: 10.1590/1413-81232020258.23682018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 10/22/2018] [Indexed: 05/30/2023] Open
Abstract
Resumo O objetivo do artigo é avaliar a contribuição do DOTS comunitário, do inglês “Directly Observed Treatment Short-Course”, nas ações de prevenção e controle da tuberculose na atenção primária no Brasil e na Etiópia, a partir das percepções e práticas dos agentes comunitários de saúde (ACS). Utilizou-se o referencial conceitual e metodológico dos sítios simbólicos de pertencimento, com suas três tipologias: caixas preta, conceitual e operacional. Empregou-se o estudo de dois casos contrastantes, triangulando e complementando informações advindas de entrevistas semiestruturadas com ACS e profissionais de saúde e também observação participante. Os achados destacam o sentido de comprometimento dos ACS como um valor importante nas ações desenvolvidas em ambos contextos. Os principais desafios são a insuficiência de capacitação e supervisão das ações realizadas (caixa conceitual), assim como as dificuldades de acesso (caixa de ferramentas), expressas em distâncias geográficas no caso etíope e em barreiras relacionadas à violência no território, não explicitadas, no contexto brasileiro. Isto implica em um esforço contínuo dos ACS para adaptar suas práticas, respeitando os valores culturais (caixa preta) que dão sentido e direção às suas ações na superação dos desafios.
Collapse
|
45
|
Mutabazi JC, Gray C, Muhwava L, Trottier H, Ware LJ, Norris S, Murphy K, Levitt N, Zarowsky C. Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study. BMC Health Serv Res 2020; 20:582. [PMID: 32586318 PMCID: PMC7318762 DOI: 10.1186/s12913-020-05381-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/31/2020] [Indexed: 11/23/2022] Open
Abstract
Background Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. Methods A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. Results Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. Conclusions Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.
Collapse
Affiliation(s)
- Jean Claude Mutabazi
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC, H3N 1X7, Canada. .,Centre de recherche en santé publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, H3L 1M3, Canada. .,Centre de Recherche du Centre Hospitalier Universitaire Sainte Justine, Montréal, QC, H3T 1C5,, Canada.
| | - Corie Gray
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia
| | - Lorrein Muhwava
- Division of Endocrinology, Department of Medicine, Faculty of Health Science, University of Cape Town, Chronic Disease Initiative for Africa, J Floor, Old Main Building, Groote Schuur Hospital, Observatory 7925, Cape Town, Western Cape, South Africa
| | - Helen Trottier
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC, H3N 1X7, Canada.,Centre de Recherche du Centre Hospitalier Universitaire Sainte Justine, Montréal, QC, H3T 1C5,, Canada
| | - Lisa Jayne Ware
- Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, 26 Chris Hani Road, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - Shane Norris
- Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, 26 Chris Hani Road, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - Katherine Murphy
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia
| | - Naomi Levitt
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia
| | - Christina Zarowsky
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montréal, QC, H3N 1X7, Canada.,Centre de recherche en santé publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, QC, H3L 1M3, Canada.,School of Public Health, University of the Western Cape, Robert Sobukwe Rd, Bellville 7535, Cape Town, Western Cape, South Africa
| |
Collapse
|
46
|
Cherian T, Hedt-Gauthier B, Nkurunziza T, Sonderman K, Gruendl MA, Nihiwacu E, Ramadhan B, Gaju E, Nahimana E, Habiyakare C, Ntakiyiruta G, Matousek A, Riviello R, Kateera F. Diagnosing Post-Cesarean Surgical Site Infections in Rural Rwanda: Development, Validation, and Field Testing of a Screening Algorithm for Use by Community Health Workers. Surg Infect (Larchmt) 2020; 21:613-620. [PMID: 32423365 DOI: 10.1089/sur.2020.062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: We aimed to develop and validate a screening algorithm to assist community health workers (CHWs) in identifying surgical site infections (SSIs) after cesarean section (c-section) in rural Africa. Methods: Patients were adult women who underwent c-section at a Rwandan rural district hospital between March and October 2017. A CHW administered a nine-item clinical questionnaire 10 ± 3 days post-operatively. Independently, a general practitioner (GP) administered the same questionnaire and assessed SSI presence by physical examination. The GP's SSI diagnosis was used as the gold standard. Using a simplified Classification and Regression Tree analysis, we identified a subset of screening questions with maximum sensitivity for the GP and CHW and evaluated the subset's sensitivity and specificity in a validation dataset. Then, we compared the subset's results when implemented in the community by CHWs with health center-reported SSI. Results: Of the 596 women enrolled, 525 (88.1%) completed the clinical questionnaire. The combination of questions concerning fever, pain, and discolored drainage maximized sensitivity for both the GPs (sensitivity = 96.8%; specificity = 85.6%) and CHWs (sensitivity = 87.1%; specificity = 73.8%). In the validation dataset, this subset had sensitivity of 95.2% and specificity of 83.3% for the GP-administered questions and sensitivity of 76.2% and specificity of 81.4% for the CHW-administered questions. In the community screening, the overall percent agreement between CHW and health center diagnoses was 81.1% (95% confidence interval: 77.2%-84.6%). Conclusions: We identified a subset of questions that had good predictive features for SSI, but its sensitivity was lower when administered by CHWs in a clinical setting, and it performed poorly in the community. Methods to improve diagnostic ability, including training or telemedicine, must be explored.
Collapse
Affiliation(s)
- Teena Cherian
- Department of Global Health and Social Medicine and Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine and Harvard Medical School, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Magdalena Anna Gruendl
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Technical University Munich, Munich, Germany
| | | | | | - Erick Gaju
- Rwanda Ministry of Health, Kigali, Rwanda
| | | | | | | | - Alexi Matousek
- Heart and Lung Institute, Sacred Heart Medical Center, Spokane, Washington, USA
| | - Robert Riviello
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
47
|
Wang GH, Nesbit C, Rankin S. Voices of home-based palliative care community health workers in rural Malawi: A mixed methods study on factors affecting role and sustainability. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1760533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Grace H. Wang
- Kaiser Permanente Redwood City, Redwood City, CA, USA
| | - Casey Nesbit
- University of California, San Francisco/San Francisco State University Graduate Program in Physical Therapy, San Francisco, CA, USA
| | - Sally Rankin
- University of California, San Francisco School of Nursing, San Francisco, CA, USA
| |
Collapse
|
48
|
Wilson E, Lee L, Klas R, Nesbit KC. Technology and rehabilitation training for community health workers: Strengthening health systems in Malawi. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:833-841. [PMID: 31808218 DOI: 10.1111/hsc.12914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 06/10/2023]
Abstract
Community health workers (CHWs) have been effectively utilised in resource-limited settings to combat a growing demand for health access that cannot be met by the current workforce. The purpose of this study was to evaluate a CHW training programme in Malawi that integrated technology into rehabilitation care delivery. This was a retrospective cross-sectional study of a training programme conducted in December 2018. The participants were a convenience sample of all active home-based palliative care CHWs at St. Gabriel's Hospital (n = 60). The data collected included the following: a written pre- and post-knowledge test, skills competency checklist and a post-training programme survey. Descriptive frequencies described skill competency and quantitative responses from the post-training programme survey. Paired t test (α = 0.05) analysis determined the significance of knowledge acquisition. Themes in the narrative responses in the post-training survey were identified. Both training programme groups showed significantly greater knowledge on the post-test (M = 9.50, SD = 0.861; M = 9.43, SD = 0.971) compared to the pre-test (M = 7.97, SD = 1.351; M = 7.90, SD = 1.900); t(29) = 6.565, p < .001; t(29) = 4.104, p < .001 for Group 1 and Group 2, respectively. All participants demonstrated skill competency in 100% of the skills. All participants responded that the training programme helped them review skills and understand how to use technology 'A lot' on a Likert scale (no, a little, some, a lot). Facilitators of their work included training programmes, phones, communication with the hospital and collaboration amongst CHWs. Barriers included transportation needs, lack of patient care supplies and lack of caregiver compliance. Overall, utilisation of their knowledge and skills from the training programmes helped their patients make improvements in mobility and function that are meaningful to their quality of life in the village. This study highlights the importance of assessing programmes in low-resource settings with a focus on feasibility and developing local capacity.
Collapse
Affiliation(s)
- Ellen Wilson
- Kaiser Permanente Vallejo Medical Center, Vallejo, CA, USA
| | - Lydia Lee
- Kaiser Permanente Richmond Medical Center, Richmond, CA, USA
| | - Rachel Klas
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathryn C Nesbit
- University of California, San Francisco, San Francisco State University, San Francisco, CA, USA
| |
Collapse
|
49
|
Chenneville T, Gabbidon K, Drake H. The HIV SEERs Project: A Qualitative Analysis of Program Facilitators' Experience. J Int Assoc Provid AIDS Care 2020; 18:2325958218822308. [PMID: 30798658 PMCID: PMC6748488 DOI: 10.1177/2325958218822308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
HIV-related stigma creates barriers to HIV testing, medication adherence, and retention in care. Guided by the principles of community-based participatory research (CBPR) and in collaboration with community health workers (CHWs), the Stigma-reduction through Education, Empowerment, and Research (SEERs) project was developed with and for youth living in Nakuru, Kenya to reduce HIV-related stigma. The purpose of this qualitative study was to examine the experiences of the CHWs serving as SEERs facilitators. To evaluate SEERs, 37 facilitators completed open-ended survey questions to gather their experiences and recommendations for future program implementation and sustainability. Participants’ mean age was 30.58 (standard deviation = 9.62), ranging from ages 18 to 53. Thematic content analysis was used to categorize (a) facilitators’ experiences and the community impact of the SEERs project, (b) lessons learned, and (c) challenges to sustainability. Recommendations will be used to modify the SEERs project, improve implementation and sustainability strategies, and may provide guidance for similar CBPR projects.
Collapse
Affiliation(s)
- Tiffany Chenneville
- 1 Department of Psychology, University of South Florida St. Petersburg, St. Petersburg, FL, USA
| | - Kemesha Gabbidon
- 1 Department of Psychology, University of South Florida St. Petersburg, St. Petersburg, FL, USA
| | - Hunter Drake
- 1 Department of Psychology, University of South Florida St. Petersburg, St. Petersburg, FL, USA
| |
Collapse
|
50
|
Kelly A, Mitra S, Elung'at J, Songok J, Jackson S, Christoffersen-Deb A. Can the financial burden of being a community health volunteer in western Kenya exacerbate poverty? Health Promot Int 2020; 35:93-101. [PMID: 30590528 DOI: 10.1093/heapro/day110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Community health volunteers (CHVs) act as vital links between communities and health facilities, bridging the health service delivery gap common in low- and middle-income countries. In 2013, changes in funding in western Kenya left most CHVs without their individual monthly stipend. In this article, we explore how the implementation of a pooled incentive model had an impact on the lives of CHVs from two counties in western Kenya. Participation in this form of table banking was meant to allow CHVs to pool their resources together and invest in income-generating activities to offset the costs of unpaid health work. A pre-post qualitative study, consisting of focus group discussions and in-depth interviews explored CHV compensation, motivations and challenges experienced in 2013 and 2015, prior to and after the implementation of this pooled incentive model. Following withdrawal of the monthly stipend, we found that CHVs continued to take on roles and responsibilities of paid health workers, motivated by shared social identities and connections to their communities. However, replacing the stipend with a pooled-group incentive model seemingly exacerbated the financial burden already experienced by this vulnerable population. This study brings into question the sustainability and viability of a volunteer community health worker programme and highlights the need to address the financial burden associated with the CHV role in western Kenya.
Collapse
Affiliation(s)
- Alyssa Kelly
- Centre for Addiction and Mental Health, Department of Education, Toronto, Canada
| | - Sanjana Mitra
- University of British Columbia, Interdisciplinary Studies Graduate Program, Vancouver, Canada
| | - Justus Elung'at
- Academic Model Providing Access to Healthcare (AMPATH), Primary Healthcare, Eldoret, Kenya
| | - Julia Songok
- Academic Model Providing Access to Healthcare (AMPATH), Primary Healthcare, Eldoret, Kenya.,Moi University College of Health Sciences, Eldoret, Kenya
| | - Suzanne Jackson
- University of Toronto, Dalla Lana School of Public Health, Department of Social and Behavioural Sciences (Health Promotion), Toronto, Ontario, Canada
| | - Astrid Christoffersen-Deb
- Academic Model Providing Access to Healthcare (AMPATH), Primary Healthcare, Eldoret, Kenya.,Moi University College of Health Sciences, Eldoret, Kenya.,University of Toronto, Faculty of Medicine, Department of Obstetrics and Gynaecology, Toronto, Ontario, Canada
| |
Collapse
|