Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis

Gender and health social enterprises in Africa: a research agenda

BACKGROUND

Health social enterprises in Africa working with community health workers (CHWs) are growing rapidly but understudied. In particular, gender equality issues related to their work has important public health and equity implications.

METHODS

Particularly suited for generating timely findings from reviews at the intersection of overlapping disciplines, we utilized the rapid evidence assessment (REA) methodology to identify key unanswered research questions at the intersection of the fields of gender equality, social enterprises and community health workers. The REA used a series of structured Google Scholar searches, expert interviews and bibliography reviews to identify 57 articles in the academic and grey literatures that met the study inclusion criteria. Articles were thematically coded to identify answers to "What are the most important research questions about the influence of gender on CHWs working with health social enterprises in Africa?"

RESULTS

The analysis identified six key unanswered research questions relating to 1) equitable systems and structures; 2) training; 3) leadership development and career enhancement; 4) payment and incentives; 5) partner, household and community support; and 6) performance.

CONCLUSION

This is the first study of its kind to identify the key unanswered research questions relevant to gender equality in health social enterprises in Africa using community health workers. As such, it sets out a research agenda for this newly emerging but rapidly developing area of research and practice with important public health implications.

Systematic mapping of existing tools to appraise methodological strengths and limitations of qualitative research: first stage in the development of the CAMELOT tool

BACKGROUND

Qualitative evidence synthesis is increasingly used alongside reviews of effectiveness to inform guidelines and other decisions. To support this use, the GRADE-CERQual approach was developed to assess and communicate the confidence we have in findings from reviews of qualitative research. One component of this approach requires an appraisal of the methodological limitations of studies contributing data to a review finding. Diverse critical appraisal tools for qualitative research are currently being used. However, it is unclear which tool is most appropriate for informing a GRADE-CERQual assessment of confidence.

METHODOLOGY

We searched for tools that were explicitly intended for critically appraising the methodological quality of qualitative research. We searched the reference lists of existing methodological reviews for critical appraisal tools, and also conducted a systematic search in June 2016 for tools published in health science and social science databases. Two reviewers screened identified titles and abstracts, and then screened the full text of potentially relevant articles. One reviewer extracted data from each article and a second reviewer checked the extraction. We used a best-fit framework synthesis approach to code checklist criteria from each identified tool and to organise these into themes.

RESULTS

We identified 102 critical appraisal tools: 71 tools had previously been included in methodological reviews, and 31 tools were identified from our systematic search. Almost half of the tools were published after 2010. Few authors described how their tool was developed, or why a new tool was needed. After coding all criteria, we developed a framework that included 22 themes. None of the tools included all 22 themes. Some themes were included in up to 95 of the tools.

CONCLUSION

It is problematic that researchers continue to develop new tools without adequately examining the many tools that already exist. Furthermore, the plethora of tools, old and new, indicates a lack of consensus regarding the best tool to use, and an absence of empirical evidence about the most important criteria for assessing the methodological limitations of qualitative research, including in the context of use with GRADE-CERQual.

Evaluating an MFI Community Health Worker Program: How microfinance group networks influence intervention outreach and impact

BACKGROUND

Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support.

METHODS

Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker's embeddedness and connectedness in the community for program success is tested using tools of social network analysis.

RESULTS

The intervention led to a 3.8% (95% confidence interval (CI) = 1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI = 3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI = 3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI = 0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties.

CONCLUSIONS

Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

What matters to women and healthcare providers in relation to interventions for the prevention of postpartum haemorrhage: A qualitative systematic review

Background

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Reducing deaths from PPH is a global challenge. The voices of women and healthcare providers have been missing from the debate around best practices for PPH prevention. The aim of this review was to identify, appraise and synthesize available evidence about the views and experiences of women and healthcare providers on interventions to prevent PPH.

Methods

We searched eight electronic databases and reference lists of eligible studies published between 1996 and 2018, reporting qualitative data on views and experiences of PPH in general, and of any specific preventative intervention(s). Authors’ findings were extracted and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed.

Results

Thirty-five studies from 29 countries met our inclusion criteria. Our results indicate that women and healthcare providers recognise the dangers of severe blood loss in the perinatal and postpartum period, but don’t always share the same beliefs about the causes and consequences of PPH. Skilled birth attendants and traditional birth attendants (TBA’s) want to prevent PPH but may lack the required resources and training. Women generally appreciate PPH prevention strategies, especially where their individual needs, beliefs and values are taken into account. Women and healthcare providers also recognize the value of using uterotonics (medications that contract the uterus) to prevent PPH but highlight safety concerns and potential misuse of the drugs as acceptability and implementation issues.

Conclusions

Based on stakeholder views and experiences, PPH prevention strategies are more likely to be successful where all stakeholders agree on the causes and consequences of severe postpartum blood loss, especially in the context of sufficient resources and effective implementation by competent, suitably trained providers.

Setting the global research agenda for community health systems: literature and consultative review

BACKGROUND

Globally, there is renewed interest in and momentum for strengthening community health systems, as also emphasized by the recent Astana Declaration. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This review aims to propose a global research agenda to strengthen CHW programs.

METHODS AND RESULTS

We conducted a search for extant systematic reviews on any intermediate factors affecting the effectiveness of CHW programs in February 2018. A total of 30 articles published after year 2000 were included. Data on research gaps were abstracted and summarized under headings based on predominant themes identified in the literature. Following this data gathering phase, two technical advisory groups comprised of experts in the field of community health-including policymakers, implementors, researchers, advocates and donors-were convened to discuss, validate, and prioritize the research gaps identified. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs, community embeddedness, institutionalization of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time.

CONCLUSIONS

As international interest and investment in CHW programs and community health systems continue to grow, it becomes critical not only to analyze the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based. Generally, the literature places a strong emphasis on the need for higher quality, more robust research.

Implementing a community-based task-shifting psychosocial intervention for individuals with psychosis in Chile: Perspectives from users

BACKGROUND

Latin America, and Chile in particular, has a rich tradition of community mental health services and programs. However, in vivo community-based psychosocial interventions, especially those with a recovery-oriented approach, remain scarce in the region. Between 2014 and 2015, a Critical Time Intervention-Task Shifting project (CTI-TS) was implemented in Santiago, Chile, as part of a larger pilot randomized control trial. CTI is a time-limited intervention delivered at a critical-time to users, is organized by phases, focuses on specific objectives and decreases in intensity over time. CTI-TS, which combines both the task-shifting strategy and the use of peers, introduces a novel approach to community mental health care that has not yet been tried in Chile.

AIMS

We aim to evaluate the feasibility, acceptability and applicability of such a community-based psychosocial intervention in urban settings in Latin America - specifically, in Santiago (Chile) from a user perspective.

METHOD

We analyzed 15 in-depth interviews ( n = 15) with service users who participated in the intervention about their perceptions and experiences with CTI-TS through thematic analysis.

RESULTS

Three themes were revealed. The first was related to the structural characteristics of CTI-TS, especially regarding the timing, duration and phasic nature of the intervention. The second pertained to the acceptability of the in vivo community-based approach. The third theme dealt with the task-shifting aspect, that is, users' perceptions of the peer support workers and the community mental health workers.

CONCLUSIONS

CTI-TS was generally acceptable in this Latin American context. Users' perspectives pointed to the need to make adjustments to some of the structural characteristics of the CTI model and to combine this type of intervention with others that can address stigma. Thus, future adaptations of CTI-TS or similar psychosocial interventions in Latin American contexts are feasible and can enhance community mental health in the region.

Purposive sampling in a qualitative evidence synthesis: a worked example from a synthesis on parental perceptions of vaccination communication

BACKGROUND

In a qualitative evidence synthesis, too much data due to a large number of studies can undermine our ability to perform a thorough analysis. Purposive sampling of primary studies for inclusion in the synthesis is one way of achieving a manageable amount of data. The objective of this article is to describe the development and application of a sampling framework for a qualitative evidence synthesis on vaccination communication.

METHODS

We developed and applied a three-step framework to sample studies from among those eligible for inclusion in our synthesis. We aimed to prioritise studies that were from a range of settings, were as relevant as possible to the review, and had rich data. We extracted information from each study about country and study setting, vaccine, data richness, and study objectives and applied the following sampling framework: 1. Studies conducted in low and middle income settings 2. Studies scoring four or more on a 5-point scale of data richness 3. Studies where the study objectives closely matched our synthesis objectives RESULTS: We assessed 79 studies as eligible for inclusion in the synthesis and sampled 38 of these. First, we sampled all nine studies that were from low and middle-income countries. These studies contributed to the least number of findings. We then sampled an additional 24 studies that scored high for data richness. These studies contributed to a larger number of findings. Finally, we sampled an additional five studies that most closely matched our synthesis objectives. These contributed to a large number of findings.

CONCLUSIONS

Our approach to purposive sampling helped ensure that we included studies representing a wide geographic spread, rich data and a focus that closely resembled our synthesis objective. It is possible that we may have overlooked primary studies that did not meet our sampling criteria but would have contributed to the synthesis. For example, two studies on migration and access to health services did not meet the sampling criteria but might have contributed to strengthening at least one finding. We need methods to cross-check for under-represented themes.

Qualitative evidence synthesis for complex interventions and guideline development: clarification of the purpose, designs and relevant methods

This paper is one of a series exploring the implications of complexity for systematic reviews and guideline development, commissioned by the WHO. The paper specifically explores the role of qualitative evidence synthesis. Qualitative evidence synthesis is the broad term for the group of methods used to undertake systematic reviews of qualitative research evidence. As an approach, qualitative evidence synthesis is increasingly recognised as having a key role to play in addressing questions relating to intervention or system complexity, and guideline development processes. This is due to the unique role qualitative research can play in establishing the relative importance of outcomes, the acceptability, fidelity and reach of interventions, their feasibility in different settings and potential consequences on equity across populations. This paper outlines the purpose of qualitative evidence synthesis, provides detail of how qualitative evidence syntheses can help establish understanding and explanation of the complexity that can occur in relation to both interventions and systems, and how qualitative evidence syntheses can contribute to evidence to decision frameworks. It provides guidance for the choice of qualitative evidence synthesis methods in the context of guideline development for complex interventions, giving 'real life' examples of where this has occurred. Information to support decision-making around choice qualitative evidence synthesis methods in the context of guideline development is provided. Approaches for reporting qualitative evidence syntheses are discussed alongside mechanisms for assessing confidence in the findings of a review.

Standardized Patients in Clinical Psychology and Psychotherapy: a Scoping Review of Barriers and Facilitators for Implementation

OBJECTIVES

The use of simulated and standardized patients (SP) is widely accepted in the medical field and, from there, is beginning to disseminate into clinical psychology and psychotherapy. The purpose of this study was therefore to systematically review barriers and facilitators that should be considered in the implementation of SP interventions specific to clinical psychology and psychotherapy.

METHODS

Following current guidelines, a scoping review was conducted. The literature search focused on the MEDLINE, PsycINFO and Web of Science databases, including Dissertation Abstracts International. After screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, a pre-defined form was piloted and used. Units of meaning with respect to barriers and facilitators were extracted and categorized inductively using content-analysis techniques. From the results, a matrix of interconnections and a network graph were compiled.

RESULTS

The 41 included publications were mainly in the fields of psychiatry and mental health nursing, as well as in training and education. The detailed category system contrasts four supercategories, i.e., which organizational and economic aspects to consider, which persons to include as eligible SPs, how to develop adequate scenarios, and how to authentically and consistently portray mental health patients.

CONCLUSIONS

Publications focused especially on the interrelation between authenticity and consistency of portrayals, on how to evoke empathy in learners, and on economic and training aspects. A variety of recommendations for implementing SP programs, from planning to training, monitoring, and debriefing, is provided, for example, ethical screening of and ongoing support for SPs.

Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review

A number of primary studies and systematic reviews focused on the contribution of community health workers (CHWs) in the delivery of essential health services. In many countries, a cadre of informal health workers also provide services on a volunteer basis [community health volunteers (CHV)], but there has been no synthesis of studies investigating their role and potential contribution across a range of health conditions; most existing studies are narrowly focused on a single condition. As this cadre grows in importance, there is a need to examine the evidence on whether and how CHVs can improve access to and use of essential health services in low- and middle-income countries (LMICs). We report an umbrella review of systematic reviews, searching PubMed, the Cochrane library, the database of abstracts of reviews of effects (DARE), EMBASE, ProQuest dissertation and theses, the Campbell library and DOPHER. We considered a review as 'systematic' if it had an explicit search strategy with qualitative or quantitative summaries of data. We used the Joanna Briggs Institute (JBI) critical appraisal assessment checklist to assess methodological quality. A data extraction format prepared a priori was used to extract data. Findings were synthesized narratively. Of 422 records initially found by the search strategy, we identified 39 systematic reviews eligible for inclusion. Most concluded that services provided by CHVs were not inferior to those provided by other health workers, and sometimes better. However, CHVs performed less well in more complex tasks such as diagnosis and counselling. Their performance could be strengthened by regular supportive supervision, in-service training and adequate logistical support, as well as a high level of community ownership. The use of CHVs in the delivery of selected health services for population groups with limited access, particularly in LMICs, appears promising. However, success requires careful implementation, strong policy backing and continual support by their managers.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

The predictive validity of the Living Goods selection tools for community health workers in Kenya: cohort study

Background

Ensuring that selection processes for Community Health Workers (CHWs) are effective is important due to the scale and scope of modern CHW programmes. However they are relatively understudied. While community involvement in selection should never be eliminated entirely, there are other complementary methods that could be used to help identify those most likely to be high-performing CHWs. This study evaluated the predictive validity of three written tests and two individual sections of a one-to-one interview used for selection into CHW posts in eight areas of Kenya.

Methods

A cohort study of CHWs working for Living Goods in eight local areas of Kenya was undertaken. Data on the selection scores, post-training assessment scores and subsequent on-the-job performance (number of household and pregnancy registrations, number of child assessments, proportion of on-time follow-ups and value of goods sold) were obtained for 547 CHWs. Kendall’s tau-b correlations between each selection score and performance outcome were calculated.

Results

None of the correlations between selection scores and outcomes reached the 0.3 threshold of an “adequate” predictor of performance. Correlations were higher for the written components of the selection process compared to the interview components, with some small negative correlations found for the latter.

Conclusions

If the measures of performance included in this study are considered critical, then further work to develop the CHW selection tools is required. This could include modifying the content of both tools or increasing the length of the written tests to make them more reliable, for if a test is not reliable then it cannot be valid. Other important outcomes not included in this study are retention in post and quality of care. Other CHW programme providers should consider evaluating their own selection tools in partnership with research teams.

Community and Drug Distributor Perceptions and Experiences of Mass Drug Administration for the Elimination of Lymphatic Filariasis: A Rapid Review of Qualitative Research

STUDY OBJECTIVES

This article presents findings from a rapid review of qualitative research conducted to inform decision makers about community and drug distributor perceptions and experiences of mass drug administration campaigns for the elimination of lymphatic filariasis. We focused on questions related to acceptability of the mass drug administration campaigns within these groups and their thoughts around the feasibility of planning and carrying out the campaigns.

METHODS

We carried out a systematic search in five databases to identify potential studies. We included studies that focused on community members and drug distributors and used qualitative methods for data collection and analysis. We conducted a thematic framework analysis using the Supporting the Use of Research Evidence framework. Due to time constraints, one author conducted the screening, extraction and data analysis.

FINDINGS

Studies found that communities lack knowledge and information about lymphatic filariasis and the mass drug administration campaigns and that this can have an impact on how many community members choose to take medication. Health workers often had a good understanding that lymphatic filariasis was a problem in their setting, of its cause and mode of transmission and that hydrocele and elephantiasis had the same cause. However, this knowledge was not as prevalent amongst community drug distributors who often had misconceptions surrounding the topic. Furthermore, studies found that the length, timing, level of community and health system involvement, access to care for side effects, inadequate numbers of drug distributors and supervisors and motivation of drug distributors influenced participation in mass drug administration campaigns. Finally, the inadequate training of drug distributors could influence community trust in the mass drug administration program and the drug distributor themselves if there was a perception that the person was uninformed or not trained to carry out their tasks.

Barriers and Facilitators to the Implementation of Interventions to Prevent Youth Violence in Latin America: A Systematic Review and Qualitative Evidence Synthesis

Youth violence in Latin America is an important public health problem. However, the evidence from preventive programs within the region to address this problem is limited. Identifying context-specific factors that facilitate or hinder the success of interventions is necessary to guarantee the successful implementation of new preventive strategies. We present a systematic review and synthesis of qualitative studies to identify factors affecting the implementation of programs to prevent youth violence in Latin America. We searched 10 electronic databases and websites of international institutions. The quality of the studies was assessed using the critical appraisal skills program checklist, while the certainty of the findings of the synthesis was assessed using the certainty of the qualitative evidence approach. We included eight papers describing five programs in Argentina, Venezuela, Peru, El Salvador, and Mexico. Most of the factors affecting the implementation of programs were aspects related to features of the programs and social/political constraints. The synthesis suggests that future programs can benefit from having a multidisciplinary and/or multisectoral approach involving different key players. At the same time, potential strategies for avoiding problems related to such active engagement should be planned via promoting effective channels for communication and supervision. The review also suggests the importance of increasing awareness and motivation toward the problem of youth violence among relevant agencies and stakeholders. While the limited volume and quality of the literature impact on the ability to draw conclusions, the results could be useful for new programs being designed and the ones seeking to be adapted from other contexts.

[Adoption and implementation of HPV self-collection sampling by CHWs in Jujuy, Argentina]

OBJECTIVE

To evaluate adoption and implementation of scaling up of HPV self-collection (SC) strategy offered doorto-door by Community Health Workers CHWs) in Jujuy, Argentina.

MATERIALS AND METHODS

A self-administered questionnaire was applied to 478 CHWs.RE-AIM model was used to evaluate adoption and implementation dimensions.

RESULTS

Adoption:81.8% offered SC and 86.4% were satis- fied with the strategy. Implementation: main problems were delays in the delivery of tubes (61.3%) and results (70.0%), lack of human resources (28.3%) and difficulties in obtaining an appointment for triage (26.1%). The main obstacle was the excessive workload of CHWs (50.2%).Training (38.0%) and the list of women to be offered the test (28.7%) were identified as facilitators.

CONCLUSIONS

The adoption of SC strategy was high among CHWs.Program strategiesshould be strengthened to motivate and reduce the excessive workload of CHWs when implementing SC strategy.

Women's and communities' views of targeted educational interventions to reduce unnecessary caesarean section: a qualitative evidence synthesis

BACKGROUND

There is continued debate about the role of women and communities in influencing rising rates of caesarean section (CS). In settings where CS rates exceed recommended levels, mothers and babies are exposed to potential harms that may outweigh the potential benefits. There is therefore a need to understand how educational interventions targeted at women and communities to reduce unnecessary CS are perceived and used. This qualitative evidence synthesis aimed to explore what women and communities say about the barriers and facilitators to intervention effectiveness for these important groups.

METHOD

Seven electronic databases were searched using predefined search terms. Studies reporting qualitative data pertaining to interventions, published between 1985 and March 2017, with no language restriction were sought. Study quality was independently assessed by two authors before qualitative evidence synthesis was undertaken using an interpretive, meta-ethnography approach. Resulting Statements of Findings were assessed using GRADE-CERQual, and summarised thematically.

RESULTS

Twelve studies were included. They were published between 2001 and 2016. Eleven were from high-income countries. Twelve Summaries of Findings encompassed the data, and were graded (moderate or high) on CerQual. The Statements of Findings are reported under three final themes: 1) Mutability of women's and communities' beliefs about birth; 2) Multiplicity of individual information needs about birth; 3) Interactions with health professionals and influence of healthcare system on actual birth method. Women and communities value educational interventions that include opportunities for dialogue, are individualised (including acknowledgement of previous birth experiences), and are consistent with available clinical care and the advice of the health professional they come into contact with.

CONCLUSION

Women's values and preferences for birth, and for information format and content, vary across populations, and evolves in individual women over time. Interactions with health professionals and health system factors can partly be responsible for changes in views. Educational interventions should take into account these dynamic interactions, as well as the women's need for emotional support and dialogue with professionals alongside information about birth. Further research is required to test these findings and the utility of their practical application, particularly in medium and low income settings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2017 CRD42017059453 .

Postnatal women's perspectives on the feasibility of introducing postpartum home visits: a Jordanian study

In Jordan, there is a deficiency in postnatal care provided to women and their newborns. This study investigated the feasibility of initiating postnatal home visits in Jordan. Thirty Jordanian mothers who had recently given birth were recruited from two governmental hospitals in the northern region of Jordan to participate in a qualitative study through face-to-face, voice-recorded interviews. The findings revealed that initiating postnatal home visits as part of postnatal care was well-received by the participants. Mothers' views and perceptions regarding postpartum home visits play an integral role in finding areas to improve postnatal services.

Supportive supervision and constructive relationships with healthcare workers support CHW performance: Use of a qualitative framework to evaluate CHW programming in Uganda

BACKGROUND

While evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries, key implementation gaps remain. Tools for assessing CHW performance and evidence on what programmatic components affect performance are lacking. This study developed and tested a qualitative evaluative framework and tool to assess CHW team performance in a district program in rural Uganda.

METHODS

A new assessment framework was developed to collect and analyze qualitative evidence based on CHW perspectives on seven program components associated with effectiveness (selection; training; community embeddedness; peer support; supportive supervision; relationship with other healthcare workers; retention and incentive structures). Focus groups were conducted with four high/medium-performing CHW teams and four low-performing CHW teams selected through random, stratified sampling. Content analysis involved organizing focus group transcripts according to the seven program effectiveness components, and assigning scores to each component per focus group.

RESULTS

Four components, 'supportive supervision', 'good relationships with other healthcare workers', 'peer support', and 'retention and incentive structures' received the lowest overall scores. Variances in scores between 'high'/'medium'- and 'low'-performing CHW teams were largest for 'supportive supervision' and 'good relationships with other healthcare workers.' Our analysis suggests that in the Bushenyi intervention context, CHW team performance is highly correlated with the quality of supervision and relationships with other healthcare workers. CHWs identified key performance-related issues of absentee supervisors, referral system challenges, and lack of engagement/respect by health workers. Other less-correlated program components warrant further study and may have been impacted by relatively consistent program implementation within our limited study area.

CONCLUSIONS

Applying process-oriented measurement tools are needed to better understand CHW performance-related factors and build a supportive environment for CHW program effectiveness and sustainability. Findings from a qualitative, multi-component tool developed and applied in this study suggest that factors related to (1) supportive supervision and (2) relationships with other healthcare workers may be strongly associated with variances in performance outcomes within a program. Careful consideration of supervisory structure and health worker orientation during program implementation are among strategies proposed to increase CHW performance.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The potential of task shifting selected maternal interventions to auxiliary midwives in Myanmar: a mixed-method study

Background

An estimated 282 women die for every 100,000 live births in Myanmar, most due to preventable causes. Auxiliary Midwives (AMWs) in Myanmar are responsible for providing a package of care during pregnancy and childbirth to women in rural hard to reach areas where skilled birth attendants (Midwives) are not accessible. This study aims to examine the role of AMWs in Myanmar and to assess the current practices of three proposed essential maternal interventions (oral supplement distribution to pregnant women; administration of misoprostol to prevent postpartum haemorrhage; management of puerperal sepsis with oral antibiotics) in order to facilitate a formal integration of these tasks to AMWs in Myanmar.

Methods

A mixed methods study was conducted in Magwe Region, Myanmar involving a survey of 262 AMWs, complemented by 15 focus group discussions with midwives (MWs), AMWs, mothers and community members, and 10 key informant interviews with health care providers at different levels within the health care system.

Results

According to current government policy, AMWs are responsible for identifying pregnant women, screening for danger signs and facilitating early referral, provision of counselling on nutrition and birth preparedness for women in hard-to-reach areas. AMWs also assist at normal deliveries and help MWs provide immunization services. In practice, they also provide oral supplements to pregnant women (84%), provide antibiotics to mothers during the puerperium (43%), and provide misoprostol to prevent postpartum haemorrhage (41%). The current practices of AMWs demonstrate the potential for task shifting on selected essential maternal interventions. However, to integrate these interventions into formal practice they must be complemented with appropriate training, clear guidelines on drug use, systematic recording and reporting, supportive monitoring and supervision and a clear political commitment towards task shifting.

Conclusion

With the current national government’s commitment towards one AMW in one village, this study highlights the potential for shifting specific maternal lifesaving tasks to AMWs.

Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the Medical Research Council (MRC) Framework

BACKGROUND

In recent years there has been much emphasis on 'research waste' caused by poor question selection, insufficient attention to previous research results, and avoidable weakness in research design, conduct and analysis. Little attention has been paid to the effect of inadequate development of interventions before proceeding to a full clinical trial.

OBJECTIVE

We therefore propose to enrich the development phase of the MRC Framework by adding crucial elements to improve the likelihood of success and enhance the fit with clinical practice METHODS: Based on existing intervention development guidance and synthesis, a comprehensive iterative intervention development approach is proposed. Examples from published reports are presented to illustrate the methodology that can be applied within each element to enhance the intervention design.

RESULTS

A comprehensive iterative approach is presented by combining the elements of the MRC Framework development phase with essential elements from existing guidance including: problem identification, the systematic identification of evidence, identification or development of theory, determination of needs, the examination of current practice and context, modelling the process and expected outcomes leading to final element: the intervention design. All elements are drawn from existing models to provide intervention developers with a greater chance of producing an intervention that is well adopted, effective and fitted to the context.

CONCLUSION

This comprehensive approach of developing interventions will strengthen the internal and external validity, minimize research waste and add value to health care research. In complex interventions in health care research, flaws in the development process immediately impact the chances of success. Knowledge regarding the causal mechanisms and interactions within the intended clinical context is needed to develop interventions that fit daily practice and are beneficial for the end-user.

Insiders and incomers: how lay public health workers' knowledge might improve public health practice

Since 2005, health trainers and other lay public health workers (LPHWs) have been increasingly active in the UK. Although elsewhere in the world LPHWs are expected to come from the communities within which they work and know that their knowledge is valued, neither is the case for LPHWs in the UK. This study sought to discover the lay knowledge of health trainers and other LPHWs, aiming to ascertain how this knowledge might more effectively be utilised within UK public health services. This paper describes a participatory and ethnographic case study research project undertaken on an anonymised urban estate in North East England. Findings were generated by a range of means including by participant observation and semi-structured interviews. Seven LPHWs took part, as did 32 other community members. This study found that the lay health knowledge of an individual UK LPHW is determined primarily by his or her position within, or in relation to, the community within which he or she works. Insider LPHWs possess an embodied knowledge and incomer LPHWs possess an experiential knowledge which, although different from one another, are essentially interpersonal in nature. Lay health knowledge can take different forms, and different LPHWs can provide different forms of lay health knowledge. Public health structures and services in the UK should make better use of all forms of LPHW knowledge, and should seek from LPHWs training on how to engage the most 'hard-to-reach' or 'difficult-to-engage' groups. Services recruiting LPHWs should decide whether they are seeking embodied insider LPHW knowledge, experiential incomer LPHW knowledge or a mixture of both.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol

BACKGROUND

Mental health is an integral part of health and well-being and yet health systems have not adequately responded to the burden of mental disorders. Integrating mental health services into primary health care (PHC) is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. PHC was formally adapted by the World Health Organization (WHO), and they have since invested enormous amounts of resources across the globe to ensure that integration of mental health services into PHC works.

METHODS

This review will use the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework approach to identify experiences of mental health integration into PHC; the findings will be reported using the "Best fit" framework synthesis. PubMed, EMBASE, PsycINFO, and Cochrane Central Register of Controlled trials (CENTRAL) will be searched including other sources like the WHO website and OpenGrey database. Assessment of bias and quality will be done at study level using two separate tools to check for the quality of evidence presented. Data synthesis will take on two synergistic approaches (qualitative and quantitative studies). Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled. The findings will be useful to a wide array of stakeholders involved in the implementation of the mental health integration into PHC.

DISCUSSION

The SPIDER framework has been chosen for this review because of its suitable application to qualitative and mixed methods research and will be used as a guide when selecting articles for inclusion. Data extracted will be synthesized using the "Best fit" framework because it has been used before and proved its suitability in producing new conceptual models for explaining decision-making and possible behaviors. Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052000.

Sharing Histories-a transformative learning/teaching method to empower community health workers to support health behavior change of mothers

BACKGROUND

One of the keys to improving health globally is promoting mothers' adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. Customarily, mothers are taught health messages which, even if simplified, are hard to remember. The challenge is how to promote learning and behavior change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong.

METHODS

In addressing that challenge, a new learning/teaching method called "Sharing Histories" is in development to improve the performance of female community health workers (CHWs) in promoting mothers' behaviors for maternal, neonatal and child health (MNCH).

RESULTS

This method builds self-confidence and empowerment of CHWs in learning sessions that are built on guided sharing of their own memories of childbearing and child care. CHWs can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing CHW programs.

CONCLUSIONS

I present here the Sharing Histories method, describe how it differs from other social and behavior change methods, and discuss selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower CHWs to be more effective change agents with other mothers in their communities, thereby contributing to the attainment of the Sustainable Development Goals.

Analysis of the association between millennium development goals 4 & 5 and the physician workforce across international economic strata

BACKGROUND

The Millennium Development Goals (MDGs) are 8 international development goals voluntarily adopted by 189 nations. The goals included health related aims to reduce the under-five child mortality rate by two-thirds (MDG4), and to reduce the maternal mortality ratio by three-quarters (MDG5). To assess the relationship between the healthcare workforce and MDGs 4-5, we examined the physician workforces of countries around the globe, in terms of the Physician Density Level (PDL, or number of physicians per 1000 population), and compared this rate across a number of years to several indicator variables specified as markers of progress towards MDG4 and MDG5.

METHODS

Data for each variable of interest were obtained from the World Bank's Millennium Development Goals and World Development Indicators databases for 208 countries and territories from 2004 to 2014, representing a ten-year period for which the most information is available. We analyzed the relationships between MDG outcomes and PDL, controlling for national income levels and other covariates, using linear mixed model regression. Dependent variables were logarithmically transformed to meet assumptions necessary for multivariate analysis.

RESULTS

In unadjusted models, an increase of every one physician per 1000 population (one unit change in PDL) lowered the risk of not being vaccinated for measles-mumps-rubella (MMR) to 29.3% (p < 0.001, 95% CI: 22.2%-38.7%) and for not receiving diphtheria-tetanus-pertussis (DTaP) vaccination rate decreased to 38.5% (p < 0.001, 95% CI: 28.7% - 51.7%). Maternal mortality rate decreased to 76.6% (p < 0.001, 95% CI: 74.3% - 79.0%), neonatal mortality decreased to 58.8% (p < 0.001, 95% CI: 54.8% - 63.2%) and under-5 mortality rate decreased to 52.1% (p < 0.001, 95% CI: 48.0% - 56.4%), with every one-unit change in PDL. Adjusted models tended to reflect unadjusted risk assessments.

CONCLUSION

The maintenance and improvement of the health workforce is a vital consideration when assessing how to achieve global development goals related to health outcomes.

Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries

BACKGROUND

Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings.

METHODS

Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC.

RESULTS

We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels.

CONCLUSIONS

Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.

Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps

BACKGROUND

Myanmar is classified as critical shortage of health workforce. In responses to limited number of trained health workforce in the hard-to-reach and remote areas, the MOH trained the Community Health Worker (CHW) as health volunteers serving these communities on a pro bono basis. This study aimed to assess the socio-economic profiles, contributions of CHW to primary health care services and their needs for supports to maintain their quality contributions in rural hard to reach areas in Myanmar.

METHODS

In 2013, cross-sectional census survey was conducted on all three groups of CHW classified by their training dates: (1) prior to 2000, (2) between 2000 and 2011, and (3) more recently trained in 2012, who are still working in 21 townships of 17 states and regions in Myanmar, using a self-administered questionnaire survey in the Burmese language.

FINDINGS

The total 715 CHWs from 21 townships had completely responded to the questionnaire. CHWs were trained to support the work of midwives in the sub-centres and health assistant and midwives in rural health centres (RHCs) such as community mobilization for immunization, advocates of safe water and sanitation, and general health education and health awareness for the citizens. CHWs were able to provide some of the services by themselves, such as treatment of simple illnesses, and they provided services to 62 patients in the last 6 months. Their contributions to primary health care services were well accepted by the communities as they are geographically and culturally accessible. However, supports from the RHC were inadequate in particular technical supervision, as well as replenishment of CHW kits and financial support for their work and transportation. In practice, 6 % of service provided by CHWs was funded by the community and 22 % by the patients. The CHW's confidence in providing health services was positively associated with their age, education, and more recent training. A majority of them intended to serve as a CHW for more than the next 5 years which was determined by their ages, confidence, and training batch.

CONCLUSIONS

CHWs are the health volunteers in the community supporting the midwives in hard-to-reach areas; given their contributions and easy access, policies to strengthen support to sustain their contributions and ensure the quality of services are recommended.

Reducing repeat pregnancies in adolescence: applying realist principles as part of a mixed-methods systematic review to explore what works, for whom, how and under what circumstances

BACKGROUND

Previous research has demonstrated emotional, psychological and educational harm to young mothers following unintended conceptions. The UK has one of the highest rates of pregnancies in adolescence in Western Europe with a high proportion of these being repeat pregnancies, making it a topic of interest for public health policy makers, and health and social care practitioners. As part of a wider mixed-methods systematic review, realist principles were applied to synthesise evidence about interventions aiming to reduce repeat pregnancies in adolescence.

METHODS

A multi-streamed, mixed-methods systematic review was conducted searching 11 major electronic databases and 9 additional databases from 1995 onwards, using key terms such as pregnancy, teen or adolescent. The principles of realist synthesis were applied to all included literature to uncover theories about what works, for whom, how and in what context. Initial theory areas were developed through evidence scoping, group discussion by the authors and stakeholder engagement to uncover context + mechanism = outcome (CMO) configurations and related narratives.

RESULTS

The searches identified 8,664 documents initially, and 403 in repeat searches, filtering to 81 included studies, including qualitative studies, randomised controlled trials, quantitative studies and grey literature. Three CMO configurations were developed. The individual experiences of young mothers' triggered self-efficacy, notions of perceived risks, susceptibility and benefits of pregnancy, resulting in the adolescent taking control of their fertility and sexual encounters. The choice between motherhood and other goals triggered notions of motivations, resulting in the adolescent managing their expectations of motherhood and controlling their fertility and sexual encounters. Barriers and facilitators to accessing services triggered notions of connectedness and self-determination; resulting in interventions that are tailored so they are relevant to young persons, and improve access to services and engagement with the issue of pregnancy in adolescence.

CONCLUSIONS

Pregnancy in adolescence is a complex issue with many factors to consider. The conceptual platform described here could help guide policy makers and professionals towards a number of areas that need to be attended to in order to increase the likelihood of an intervention working to prevent rapid repeat pregnancy in adolescence.

TRIAL REGISTRATION

PROSPERO CRD42012003168.

Interventions to optimise the care continuum for chronic viral hepatitis: a systematic review and meta-analyses

BACKGROUND

Advances in therapy for hepatitis B virus (HBV) and hepatitis C virus (HCV) have ushered in a new era in chronic hepatitis treatment. To maximise the effectiveness of these medicines, individuals must be engaged and retained in care. We analysed operational interventions to enhance chronic viral hepatitis testing, linkage to care, treatment uptake, adherence, and viral suppression or cure.

METHODS

We did a systematic review of operational interventions, and did meta-analyses for sufficiently comparable data. We searched PubMed, Embase, WHO library, International Clinical Trials Registry Platform, PsycINFO, and CINAHL for randomised controlled trials and controlled non-randomised studies that examined operational interventions along the chronic viral hepatitis care continuum, published in English up to Dec 31, 2014. We included non-pharmaceutical intervention studies with primary or secondary outcomes of testing, linkage to care, treatment uptake, treatment adherence, treatment completion, treatment outcome, or viral endpoints. We excluded dissertations and studies of children only. Data were extracted by two independent reviewers, with disagreements resolved by a third reviewer. Studies were assessed for bias. Data from similar interventions were pooled and quality of evidence was assessed using GRADE. This study was registered in PROSPERO (42014015094).

FINDINGS

We identified 7583 unduplicated studies, and included 56 studies that reported outcomes along the care continuum (41 for HCV and 18 for HBV). All studies except one were from high-income countries. Lay health worker HBV test promotion interventions increased HBV testing rates (relative risk [RR] 2·68, 95% CI 1·82-3·93). Clinician reminders to prompt HCV testing during clinical visits increased HCV testing rates (3·70, 1·81-7·57). Nurse-led educational interventions improved HCV treatment completion (1·14, 1·05-1·23) and cure (odds ratio [OR] 1·93, 95% CI 1·44-2·59). Coordinated mental health, substance misuse, and hepatitis treatment services increased HCV treatment uptake (OR 3·03, 1·24-7·37), adherence (RR 1·22, 1·05-1·41), and cure (RR 1·21, 1·07-1·38) compared with usual care.

INTERPRETATION

Several simple, inexpensive operational interventions can substantially improve engagement and retention along the chronic viral hepatitis care continuum. Further operational research to inform scale-up of hepatitis services is needed in low-income and middle-income countries.

FUNDING

World Health Organization and US Fulbright Program.

Auxiliary midwives in hard to reach rural areas of Myanmar: filling MCH gaps

BACKGROUND

Auxiliary Midwives (AMWs) are community health volunteers supporting the work of midwives, especially maternal and child health services in hard to-reach areas in Myanmar. This paper assessed the contributions of AMW to maternal and child health services, factors influencing their productivity and their willingness to serve the community.

METHOD

The study applied quantitative cross-sectional survey using census method. Total of 1,185 AMWs belonging to three batches: trained prior to 2000, between 2000 and 2011, and in 2012, from 21 townships of 17 states and regions in Myanmar participated in the study. Multiple logit regression was used to examine the impact of age, marital status, education, domicile, recruitment pattern and 'batch of training', on AMW's confidence level in providing care, and their intention to serve the community more than 5 years.

RESULTS

All AMWs were able to provide essential maternal and child health services including antenatal care, normal delivery and post-natal care. They could identify and refer high-risk pregnancies to larger health facilities for proper management. On average, 9 deliveries, 11 antenatal and 9 postnatal cases were performed by an AMW during the six months prior to this study. AMWs had a comparative advantage for longer service in hard-to-reach villages where they lived, spoke the same dialect as the locals, understood the socio-cultural dimensions, and were well accepted by the community. Despite these contributions, 90 % of the respondents expressed receiving no adequate supervision, refresher training, replenishment of the AMW kits and transportation cost. AMWs in the elder age group are significantly more confident in taking care of the patients than those in the younger groups. Over 90 % of the respondents intended to stay more than five years in the community. The confidence in catering services appeared to have significant association with a longer period of stay in AMW jobs as evidenced by the odds ratio of 3.5, compared to those reporting unconfident.

CONCLUSIONS

Comprehensive support system and national policy are needed to sustain and strengthen the contributions of AMWs, in sharing the workload of midwives, particularly in hard-to-reach areas of Myanmar.

Inspiring health worker motivation with supportive supervision: a survey of lady health supervisor motivating factors in rural Pakistan

Background

Community health worker motivation is an important consideration for improving performance and addressing maternal, newborn, and child health in low and middle-income countries. Therefore, identifying health system interventions that address motivating factors in resource-strained settings is essential. This study is part of a larger implementation research project called Nigraan, which is intervening on supportive supervision in the Lady Health Worker Programme to improve community case management of pneumonia and diarrhea in rural Pakistan. This study explored the motivation of Lady Health Supervisors, a cadre of community health workers, with particular attention to their views on supportive supervision.

Methods

Twenty-nine lady health supervisors enrolled in Nigraan completed open-ended structured surveys with questions exploring factors that affect their motivation. Thematic analysis was conducted using a conceptual framework categorizing motivating factors at individual, community, and health system levels.

Results

Supportive supervision, recognition, training, logistics, and salaries are community and health system motivating factors for lady health supervisors. Lady health supervisors are motivated by both their role in providing supportive supervision to lady health workers and by the supervisory support received from their coordinators and managers. Family support, autonomy, and altruism are individual level motivating factors.

Conclusions

Health system factors, including supportive supervision, are crucial to improving lady health supervisor motivation. As health worker motivation influences their performance, evaluating the impact of health system interventions on community health worker motivation is important to improving the effectiveness of community health worker programs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1641-x) contains supplementary material, which is available to authorized users.

What does the literature tell us about health workers' experiences of task-shifting projects in sub-Saharan Africa? A systematic, qualitative review

AIMS AND OBJECTIVES

To review systematically, qualitative literature covering the implementation of task shifting in sub-Saharan Africa to address the growing interest in interventions of this kind. This review aims to distil the key practical findings to both guide a specific project aiming to improve the quality of neonatal care in Kenya and to contribute to the broader literature.

BACKGROUND

Task-shifting programmes aim to improve access to healthcare by delegating specific tasks from higher to lower skilled health workers. Evidence suggests that task-shifting programmes in sub-Saharan Africa may improve patient outcomes, but they have also been criticised for providing fragmented, unsustainable services. This systematic review of qualitative literature summarises factors affecting implementation of task shifting and how such interventions in sub-Saharan Africa may have affected health workers' feelings about their own positions and their ability to provide care.

DESIGN

Following literature search, a modified Critical Appraisal Skills Program (CASP) framework was used to assess quality. Thereafter, analysis adopted a thematic synthesis approach.

METHODS

A systematic literature search identified qualitative studies examining task -shifting interventions in sub-Saharan Africa. Thematic synthesis was used to identify overarching themes arising from across the studies and infer how task-shifting interventions may impact on the health workers from whom tasks are being shifted.

RESULTS

From the 230 studies screened, 13 met the inclusion criteria. Overarching themes identified showed that task shifting has been associated with jurisdictional debates linked to new cadres working beyond their scope of practice, and tension around compensation and career development for those taking on tasks that were being delegated.

CONCLUSIONS

Based on the qualitative data available, it appears that task shifting may negatively impact the sense of agency and the ability to perform of health workers' from whom tasks are shifted. The potential implications of task shifting on all health workers should be considered prior to implementing task-shifting solutions.

The swine flu vaccine, public attitudes, and researcher interpretations: a systematic review of qualitative research

BACKGROUND

During pandemics, health authorities may be uncertain about the spread and severity of the disease and the effectiveness and safety of available interventions. This was the case during the swine flu (H1N1) pandemic of 2009-2010, and governments were forced to make decisions despite these uncertainties. While many countries chose to implement wide scale vaccination programmes, few accomplished their vaccination goals. Many research studies aiming to explore barriers and facilitators to vaccine uptake have been conducted in the aftermath of the pandemic, including several qualitative studies.

AIMS

1. To explore public attitudes to the swine flu vaccine in different countries through a review of qualitative primary studies. 2. To describe and discuss the implications drawn by the primary study authors.

METHODS

Systematic review of qualitative research studies, using a broadly comparative cross case-study approach. Study quality was appraised using an adaptation of the Critical Appraisal Skills Programme (CASP) quality assessment tool.

RESULTS

The review indicates that the public had varying opinions about disease risk and prevalence and had concerns about vaccine safety. Most primary study authors concluded that participants were uninformed, and that more information about the disease and the vaccine would have led to an increase in vaccine uptake. We find these conclusions problematic. We suggest instead that people's questions and concerns were legitimate given the uncertainties of the situation at the time and the fact that the authorities did not have the necessary information to convince the public. Our quality assessment of the included studies points to a lack of reflexivity and a lack of information about study context. We suggest that these study weaknesses are tied to primary study authors' lack of acknowledgement of the uncertainties surrounding the disease and the vaccine.

CONCLUSION

While primary study authors suggest that authorities could increase vaccine uptake through increased information, we suggest instead that health authorities should be more transparent in their information and decision-making processes in future pandemic situations.

Protocol-developing meta-ethnography reporting guidelines (eMERGe)

Background

Designing and implementing high-quality health care services and interventions requires robustly synthesised evidence. Syntheses of qualitative research studies can provide evidence of patients’ experiences of health conditions; intervention feasibility, appropriateness and acceptability to patients; and advance understanding of health care issues. The unique, interpretive, theory-based meta-ethnography synthesis approach is suited to conveying patients’ views and developing theory to inform service design and delivery. However, meta-ethnography reporting is often poor quality, which discourages trust in, and use of, meta-ethnography findings. Users of evidence syntheses require reports that clearly articulate analytical processes and findings. Tailored research reporting guidelines can raise reporting standards but none exists for meta-ethnography. This study aims to create an evidence-based meta-ethnography reporting guideline articulating the methodological standards and depth of reporting required to improve reporting quality.

Methods/design

The mixed-methods design of this National Institute of Health Research-funded study (http://www.stir.ac.uk/emerge/) follows good practice in research reporting guideline development comprising: (1) a methodological systematic review (PROSPERO registration: CRD42015024709) to identify recommendations and guidance in conducting/reporting meta-ethnography; (2) a review and audit of published meta-ethnographies to identify good practice principles and develop standards in conduct/reporting; (3) an online workshop and Delphi studies to agree guideline content with 45 international qualitative synthesis experts and 45 other stakeholders including patients; (4) development and wide dissemination of the guideline and its accompanying detailed explanatory document, a report template for National Institute of Health Research commissioned meta-ethnographies, and training materials on guideline use.

Discussion

Meta-ethnography, devised in the field of education, is now used widely in other disciplines. Methodological advances relevant to meta-ethnography conduct exist. The extent of discipline-specific adaptations of meta-ethnography and the fit of any adaptions with the underpinning philosophy of meta-ethnography require investigation. Well-reported meta-ethnography findings could inform clinical decision-making. A bespoke meta-ethnography reporting guideline is needed to improve reporting quality, but to be effective potential users must know it exists, trust it and use it. Therefore, a rigorous study has been designed to develop and promote a guideline. By raising reporting quality, the guideline will maximise the likelihood that high-quality meta-ethnographies will contribute robust evidence to improve health care and patient outcomes.

Developing and Optimising the Use of Logic Models in Systematic Reviews: Exploring Practice and Good Practice in the Use of Programme Theory in Reviews

BACKGROUND

Logic models are becoming an increasingly common feature of systematic reviews, as is the use of programme theory more generally in systematic reviewing. Logic models offer a framework to help reviewers to 'think' conceptually at various points during the review, and can be a useful tool in defining study inclusion and exclusion criteria, guiding the search strategy, identifying relevant outcomes, identifying mediating and moderating factors, and communicating review findings.

METHODS AND FINDINGS

In this paper we critique the use of logic models in systematic reviews and protocols drawn from two databases representing reviews of health interventions and international development interventions. Programme theory featured only in a minority of the reviews and protocols included. Despite drawing from different disciplinary traditions, reviews and protocols from both sources shared several limitations in their use of logic models and theories of change, and these were used almost unanimously to solely depict pictorially the way in which the intervention worked. Logic models and theories of change were consequently rarely used to communicate the findings of the review.

CONCLUSIONS

Logic models have the potential to be an aid integral throughout the systematic reviewing process. The absence of good practice around their use and development may be one reason for the apparent limited utility of logic models in many existing systematic reviews. These concerns are addressed in the second half of this paper, where we offer a set of principles in the use of logic models and an example of how we constructed a logic model for a review of school-based asthma interventions.

Community Health Workers as a Component of the Health Care Team

In restructuring the delivery of primary care to improve the wellness of a community, every community must review its own circumstances for factors such as resources and capacities, health concerns, social and political perspectives, and competing priorities. Strengthening the health care team with community health workers to create a patient-centered medical home can enhance health care access and outcomes. Community health workers can serve as critical connectors between health systems and communities; they facilitate access to and improve quality and culturally sensitive medical care, emphasizing preventive and primary care.

Seeing and Holding Baby: Systematic Review of Clinical Management and Parental Outcomes After Stillbirth

BACKGROUND

In 2009 there were an estimated 2.6 million stillbirths worldwide. In the United States, a 2007 systematic review found little consensus about professional behaviors perceived by parents to be most helpful or most distressing. In the United Kingdom, a bereaved parents' organization has highlighted discordance between parental views and clinical guidelines that recommend clinicians do not encourage parents to see and hold their baby. The objective of this review was to identify and synthesize available research reporting parental outcomes relating to seeing and holding.

METHODS

We undertook a systematic review. We included studies of any design, reporting parental experiences and outcomes. Electronic searches (PubMed and PsychINFO) were conducted in January 2014. Three authors independently screened and assessed the quality of the studies before abstracting data and undertaking thematic analysis.

RESULTS

We reviewed 741 records and included 23 studies (10 quantitative, 12 qualitative, and 1 mixed-method). Twenty-one studies suggested positive outcomes for parents who saw or held their baby. Increased psychological morbidity was associated with current pregnancy, choice not to see their baby, lack of time with their baby and/or insufficient mementos. Three themes were formulated "positive effects of contact within a traumatic life event," "importance of role of health professionals," and "impact on mothers and fathers: similarities and differences."

CONCLUSIONS

Stillbirth is a risk factor for increased psychological morbidity. Parents seeing and holding their stillborn baby can be beneficial to their future well-being. Since 2007, there has been a proliferation of studies that challenge clinical guidelines recommending that clinicians do not encourage parental contact.

Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach

BACKGROUND

There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated.

METHODS

We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component.

RESULTS

We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system.

CONCLUSIONS

We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

Innovation in health service delivery: integrating community health assistants into the health system at district level in Zambia

Background

To address the huge human resources for health gap in Zambia, the Ministry of Health launched the National Community Health Assistant Strategy in 2010. The strategy aims to integrate community-based health workers into the health system by creating a new group of workers, called community health assistants (CHAs). However, literature suggests that the integration process of national community-based health worker programmes into health systems has not been optimal. Conceptually informed by the diffusion of innovations theory, this paper qualitatively aimed to explore the factors that shaped the acceptability and adoption of CHAs into the health system at district level in Zambia during the pilot phase.

Methods

Data gathered through review of documents, 6 focus group discussions with community leaders, and 12 key informant interviews with CHA trainers, supervisors and members of the District Health Management Team were analysed using thematic analysis.

Results

The perceived relative advantage of CHAs over existing community-based health workers in terms of their quality of training and scope of responsibilities, and the perceived compatibility of CHAs with existing groups of health workers and community healthcare expectations positively facilitated the integration process. However, limited integration of CHAs in the district health governance system hindered effective programme trialability, simplicity and observability at district level. Specific challenges at this level included a limited information flow and sense of programme ownership, and insufficient documentation of outcomes. The district also had difficulties in responding to emergent challenges such as delayed or non-payment of CHA incentives, as well as inadequate supervision and involvement of CHAs in the health posts where they are supposed to be working. Furthermore, failure of the health system to secure regular drug supplies affected health service delivery and acceptability of CHA services at community level.

Conclusion

The study has demonstrated that implementation of policy guidelines for integrating community-based health workers in the health system may not automatically guarantee successful integration at the local or district level, at least at the start of the process. The study reiterates the need for fully integrating such innovations into the district health governance system if they are to be effective.

Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.

A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.

When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

Evidence and AIDS activism: HIV scale-up and the contemporary politics of knowledge in global public health

The HIV epidemic is widely recognised as having prompted one of the most remarkable intersections ever of illness, science and activism. The production, circulation, use and evaluation of empirical scientific 'evidence' played a central part in activists' engagement with AIDS science. Previous activist engagement with evidence focused on the social and biomedical responses to HIV in the global North as well as challenges around ensuring antiretroviral treatment (ART) was available in the global South. More recently, however, with the roll-out and scale-up of large public-sector ART programmes and new multi-dimensional prevention efforts, the relationships between evidence and activism have been changing. Scale-up of these large-scale treatment and prevention programmes represents an exciting new opportunity while bringing with it a host of new challenges. This paper examines what new forms of evidence and activism will be required to address the challenges of the scaling-up era of HIV treatment and prevention. It reviews some recent controversies around evidence and HIV scale-up and describes the different forms of evidence and activist strategies that will be necessary for a robust response to these new challenges.

A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services

OBJECTIVE

to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation.

DESIGN

systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach.

SETTING

midwifery services in any setting in low-, middle-, and high-income countries.

PARTICIPANTS

midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders.

INTERVENTIONS

task shifting to and from midwives.

FINDINGS

thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting.

KEY CONCLUSIONS

this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater.

IMPLICATIONS FOR PRACTICE

evidence from the review fed into the World Health Organisation's 'Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting' guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.