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Gupta A, Khan S. Importance of Community Health Workers for Maternal Health Care Management. Public Health Rev 2024; 45:1606803. [PMID: 38455869 PMCID: PMC10917972 DOI: 10.3389/phrs.2024.1606803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/07/2024] [Indexed: 03/09/2024] Open
Abstract
Objectives: Community Health Workers (CHWs) are important healthcare professionals and key members of team. The purpose of this research is to identify the roles and responsibilities of CHWs in developed and developing countries who provide healthcare assistance to pregnant and lactating women. Methods: For this particular study, a comparison was conducted between CHWs role in seven developed countries, seven South Asian developing countries, and India, with special emphasis on improving maternal health status. Results: CHW programs are essential in communities, institutional health programs, and outreach delivery systems. Without active community involvement, CHWs cannot reach their full potential. Developed countries have frameworks for CHWs, such as the Swasthya Shebika Program, Village Health Worker Cadret, Lady Health Worker Programme, and Accredited Social Health Activist program. CHWs are well-paid in developed nations and work with marginalized groups to spread health messages. However, up to 60% of community health workers in low- and lower-middle-income countries do not receive remuneration. Conclusion: Health systems must support CHWs in choosing technical interventions and providing necessary training, supervision, and logistical support.
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Affiliation(s)
- Archana Gupta
- Department of Home Science, Faculty of Agricultural Sciences, Aligarh Muslim University, Aligarh, India
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Ballard M, Olaniran A, Iberico MM, Rogers A, Thapa A, Cook J, Aranda Z, French M, Olsen HE, Haughton J, Lassala D, Carpenter Westgate C, Malitoni B, Juma M, Perry HB. Labour conditions in dual-cadre community health worker programmes: a systematic review. Lancet Glob Health 2023; 11:e1598-e1608. [PMID: 37734803 DOI: 10.1016/s2214-109x(23)00357-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/23/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Health care delivered by community health workers reduces morbidity and mortality while providing a considerable return on investment. Despite growing consensus that community health workers, a predominantly female workforce, should receive a salary, many community health worker programmes take the form of dual-cadre systems, where a salaried cadre of community health workers works alongside a cadre of unsalaried community health workers. We aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre programmes. METHODS We did a systematic review of available evidence from peer-reviewed databases and grey literature from database inception to Aug 2, 2021, for studies on unsalaried community health worker cadres in dual-cadre systems. Editorials, protocols, guidelines, or conference reports were excluded in addition to studies about single-tier community health worker programmes and those reporting on only salaried cadres of community health workers in a dual-cadre system. We extracted data on remuneration, workload, task complexity, and self-reported experiences of community health workers. Three models were created: a minimum model with the shortest time and frequency per task documented in the literature, a maximum model with the longest time, and a median model. Labour exploitation was defined as being engaged in work below the country's minimum wage together with excessive work hours or complex tasks. The study was registered with PROSPERO, CRD42021271500. FINDINGS We included 117 reports from 112 studies describing community health workers in dual-cadre programmes across 19 countries. The majority of community health workers were female. 13 (59%) of 22 unsalaried community health worker cadres and one (10%) of ten salaried cadres experienced labour exploitation. Three (17%) of 18 unsalaried community health workers would need to work more than 40 h per week to fulfil their assigned responsibilities. Unsalaried community health worker cadres frequently reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload. INTERPRETATION Unsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services. FUNDING None.
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Affiliation(s)
- Madeleine Ballard
- Community Health Impact Coalition, London, UK; Department of Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | - M Matías Iberico
- Partners in Health Mexico, Ángel Albino Corzo, México; Tulane University School of Medicine, New Orleans, LA, USA
| | - Ash Rogers
- Lwala Community Alliance, Nashville, TN, USA
| | | | | | - Zeus Aranda
- Partners in Health Mexico, Ángel Albino Corzo, México; El Colegio de la Frontera Sur, San Cristóbal de las Casas, México
| | | | | | - Jessica Haughton
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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D'Ambruoso L, Abruquah NA, Mabetha D, van der Merwe M, Goosen G, Sigudla J, Witter S. Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district. HUMAN RESOURCES FOR HEALTH 2023; 21:66. [PMID: 37596628 PMCID: PMC10439531 DOI: 10.1186/s12960-023-00853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. METHODS CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. RESULTS CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. CONCLUSIONS Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.
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Affiliation(s)
- Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Public Health, National Health Service (NHS) Grampian, Aberdeen, Scotland, UK.
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
| | - Nana Akua Abruquah
- The University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Denny Mabetha
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
| | - Maria van der Merwe
- Aberdeen Centre for Health Data Science, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Maria Van Der Merwe Consulting, White River, South Africa
| | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, Scotland, UK
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Olawoye O, Salami KK, Azeez A, Adebola P, Sarimiye T, Imaledo J, Realini T, Hauser MA, Ashaye A. The social construction of genomics and genetic analysis in ocular diseases in Ibadan, South-western Nigeria. PLoS One 2022; 17:e0278286. [PMID: 36454870 PMCID: PMC9714877 DOI: 10.1371/journal.pone.0278286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
Genomics, an emerging field to improve public health practice, has potential benefits to understanding ocular diseases. This study explored the social construction of genomics in ocular diseases in the blind community in Ibadan, Nigeria, through two focus group discussions and twelve in-depth interview sessions conducted among people living with ocular disorders. The data were thematic and content-analysed. Although the participants had limited knowledge about ocular diseases, genomics, and their nexus, they maintained a positive attitude toward its potential benefits. This informed their willingness to participate in genomics testing for ocular diseases. The participants preferred saliva-based sample collection over blood-based, and expressed concern for the procedure and accrued benefits of genomics studies. Thus, public sensitisation about ocular diseases and client-centred genomics testing procedures should be engendered.
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Affiliation(s)
- Olusola Olawoye
- Department of Ophthalmology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Ophthalmology, University College Hospital Ibadan, Ibadan, Nigeria
| | - Kabiru K. Salami
- Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
| | - Abolaji Azeez
- Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
| | - Precious Adebola
- Department of Ophthalmology, University College Hospital Ibadan, Ibadan, Nigeria
| | - Tarela Sarimiye
- Department of Ophthalmology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Ophthalmology, University College Hospital Ibadan, Ibadan, Nigeria
| | - John Imaledo
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Tony Realini
- Department of Ophthalmology and Visual Sciences, School of Medicine, West Virginia University, Morgantown, West Virginia, United States of America
| | - Michael A. Hauser
- Department of Medicine, Duke University School of Medicine, Duke University, Durham, North Carolina, United States of America
- Department of Ophthalmology, Duke University School of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Adeyinka Ashaye
- Department of Ophthalmology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Ophthalmology, University College Hospital Ibadan, Ibadan, Nigeria
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Exploring Barriers to One Health Antimicrobial Stewardship in Sri Lanka: A Qualitative Study among Healthcare Professionals. Antibiotics (Basel) 2022; 11:antibiotics11070968. [PMID: 35884221 PMCID: PMC9311535 DOI: 10.3390/antibiotics11070968] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 12/04/2022] Open
Abstract
Antimicrobial resistance (AMR) is a global health threat, but little is known about the perceptions regarding antimicrobials and AMR among healthcare professionals in Sri Lanka. This research aimed to take a One Health approach to explore the knowledge, attitudes and perceptions of antibiotic stewardship and AMR among healthcare professionals in Sri Lanka. A qualitative study, using telephone interviews, allowing for an in-depth exploration of attitudes, beliefs and perspectives was conducted. Healthcare professionals from both the medical and veterinary sectors were included (n = 29). Interviews were conducted by an independent interviewer and were audio-recorded and transcribed. Conventional qualitative content analysis was undertaken. Four main categories were identified: (1) understanding of AMR and observing AMR, (2) barriers to antimicrobial stewardship, (3) personal factors in, and as a result of, inappropriate antibiotic usage and (4) how to tackle AMR. Healthcare professionals showed poor awareness regarding the spread of AMR and identified inappropriate prescribing behaviours by their inter- and intra-professional colleagues. Patient demands and the influence of pharmaceutical companies were factors contributing to poor prescribing behaviour. Suggestions for the future are stricter regulation of AMR control policy, effective government involvement, and awareness campaigns for healthcare professionals and the public.
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Robbins T, Hanlon C, Kelly AH, Gidiri MF, Musiyiwa M, Silverio SA, Shennan AH, Sandall J. Pills and prayers: a comparative qualitative study of community conceptualisations of pre-eclampsia and pluralistic care in Ethiopia, Haiti and Zimbabwe. BMC Pregnancy Childbirth 2021; 21:716. [PMID: 34702209 PMCID: PMC8547033 DOI: 10.1186/s12884-021-04186-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background Pre-eclampsia is a leading cause of preventable maternal and perinatal deaths globally. While health inequities remain stark, removing financial or structural barriers to care does not necessarily improve uptake of life-saving treatment. Building on existing literature elaborating the sociocultural contexts that shape behaviours around pregnancy and childbirth can identify nuanced influences relating to pre-eclampsia care. Methods We conducted a cross-cultural comparative study exploring lived experiences and understanding of pre-eclampsia in Ethiopia, Haiti and Zimbabwe. Our primary objective was to examine what local understandings of pre-eclampsia might be shared between these three under-resourced settings despite their considerable sociocultural differences. Between August 2018 and January 2020, we conducted 89 in-depth interviews with individuals and 17 focus group discussions (n = 106). We purposively sampled perinatal women, survivors of pre-eclampsia, families of deceased women, partners, older male and female decision-makers, traditional birth attendants, religious and traditional healers, community health workers and facility-based health professionals. Template analysis was conducted to facilitate cross-country comparison drawing on Social Learning Theory and the Health Belief Model. Results Survivors of pre-eclampsia spoke of their uncertainty regarding symptoms and diagnosis. A lack of shared language challenged coherence in interpretations of illness related to pre-eclampsia. Across settings, raised blood pressure in pregnancy was often attributed to psychosocial distress and dietary factors, and eclampsia linked to spiritual manifestations. Pluralistic care was driven by attribution of causes, social norms and expectations relating to alternative care and trust in biomedicine across all three settings. Divergence across the contexts centred around nuances in religious or traditional practices relating to maternal health and pregnancy. Conclusions Engaging faith and traditional caregivers and the wider community offers opportunities to move towards coherent conceptualisations of pre-eclampsia, and hence greater access to potentially life-saving care. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04186-6.
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Affiliation(s)
- Tanya Robbins
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, and WHO Collaborating Centre for Mental Health Research and Training, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ann H Kelly
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Mickias Musiyiwa
- Department of History, Heritage and Knowledge Systems, Faculty of Arts and Humanities, University of Zimbabwe, Harare, Zimbabwe
| | - Sergio A Silverio
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK
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Cost-effectiveness analysis of integrated community case management delivery models utilizing drug sellers and community health workers for treatment of under-five febrile cases of malaria, pneumonia, diarrhoea in rural Uganda. Malar J 2021; 20:407. [PMID: 34663345 PMCID: PMC8524984 DOI: 10.1186/s12936-021-03944-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background Malaria, pneumonia and diarrhoea continue to be the leading causes of death in children under the age of five years (U5) in Uganda. To combat these febrile illnesses, integrated community case management (iCCM) delivery models utilizing community health workers (CHWs) or drug sellers have been implemented. The purpose of this study is to compare the cost-effectiveness of delivering iCCM interventions via drug sellers versus CHWs in rural Uganda. Methods This study was a cost-effectiveness analysis to compare the iCCM delivery model utilizing drug sellers against the model using CHWs. The effect measure was the number of appropriately treated U5 children, and data on effectiveness came from a quasi-experimental study in Southwestern Uganda and the inSCALE cross-sectional household survey in eight districts of mid-Western Uganda. The iCCM interventions were costed using the micro-costing (ingredients) approach, with costs expressed in US dollars. Cost and effect data were linked together using a decision tree model and analysed using the Amua modelling software. Results The costs per 100 treated U5 children were US$591.20 and US$298.42 for the iCCM trained-drug seller and iCCM trained-CHW models, respectively, with 30 and 21 appropriately treated children in the iCCM trained-drug seller and iCCM trained-CHW models. When the drug seller arm (intervention) was compared to the CHW arm (control), an incremental effect of 9 per 100 appropriately treated U5 children was observed, as well as an incremental cost of US$292.78 per 100 appropriately treated children, resulting in an incremental cost-effectiveness ratio (ICER) of US$33.86 per appropriately treated U5 patient. Conclusion Since both models were cost-effective compared to the do-nothing option, the iCCM trained-drug seller model could complement the iCCM trained-CHW intervention as a strategy to increase access to quality treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03944-3.
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LeBan K, Kok M, Perry HB. Community health workers at the dawn of a new era: 9. CHWs' relationships with the health system and communities. Health Res Policy Syst 2021; 19:116. [PMID: 34641902 PMCID: PMC8506091 DOI: 10.1186/s12961-021-00756-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This is the ninth paper in our series, "Community Health Workers at the Dawn of a New Era". Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities. METHODS The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes. RESULTS The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders. CONCLUSION To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.
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Affiliation(s)
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Henry B Perry
- Department of International Health, Health Systems Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Nyanja N, Nyamu N, Nyaga L, Chabeda S, Lusambili A, Temmerman M, Mantel M, Ngugi A. Application of the Ultra-Poverty Graduation Model in understanding community health volunteers' preferences for socio-economic empowerment strategies to enhance retention: a qualitative study in Kilifi, Kenya. HUMAN RESOURCES FOR HEALTH 2021; 19:104. [PMID: 34454506 PMCID: PMC8400398 DOI: 10.1186/s12960-021-00645-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 08/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND A significant shortage of healthcare workforce exists globally. To achieve Universal Healthcare coverage, governments need to enhance their community-based health programmes. Community health volunteers (CHVs) are essential personnel in achieving this objective. However, their ability to earn a livelihood is compromised by the voluntary nature of their work; hence, the high attrition rates from community-based health programmes. There is an urgent need to support CHVs become economically self-reliant. We report here on the application of the Ultra-Poverty Graduation (UPG) Model to map CHVs' preferences for socio-economic empowerment strategies that could enhance their retention in a rural area in Kenya. METHODS This study adopted an exploratory qualitative approach. Using a semi-structured questionnaire, we conducted 10 Focus Group Discussions with the CHVs and 10 Key Informant Interviews with County and Sub-county Ministry of Health and Ministry of Agriculture officials including multi-lateral stakeholders' representatives from two sub-counties in the area. Data were audio-recorded and transcribed verbatim and transcripts analysed in NVivo. Researcher triangulation supported the first round of analysis. Findings were mapped and interpreted using a theory-driven analysis based on the six-step Ultra-Poverty Graduation Model. RESULTS We mapped the UPG Model's six steps onto the results of our analyses as follows: (1) initial asset transfer of in-kind goods like poultry or livestock, mentioned by the CHVs as a necessary step; (2) weekly stipends with consumption support to stabilise consumption; (3) hands-on training on how to care for assets, start and run a business based on the assets transferred; (4) training on and facilitation for savings and financial support to build assets and instil financial discipline; (5) healthcare provision and access and finally (6) social integration. These strategies were proposed by the CHVs to enhance economic empowerment and aligned with the UPG Model. CONCLUSION These results provide a user-defined approach to identify and assess strategic needs of and approaches to CHVs' socio-economic empowerment using the UPG model. This model was useful in mapping the findings of our qualitative study and in enhancing our understanding on how these needs can be addressed in order to economically empower CHVs and enhance their retention in our setting.
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Affiliation(s)
- Njeri Nyanja
- Department of Family Medicine, Aga Khan University, Nairobi, Kenya.
| | - Nelson Nyamu
- Department of Family Medicine, Aga Khan University, Nairobi, Kenya
| | - Lucy Nyaga
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
| | | | | | - Marleen Temmerman
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Michaela Mantel
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anthony Ngugi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
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Ludwick T, Morgan A, Kane S, Kelaher M, McPake B. The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature. Health Policy Plan 2021; 35:1039-1052. [PMID: 32494801 DOI: 10.1093/heapol/czaa049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/12/2022] Open
Abstract
Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.
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Affiliation(s)
- Teralynn Ludwick
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, 333 Exhibition Street, Carlton, Melbourne, VIC, 3004, Australia
| | - 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
| | - 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
| | - Margaret Kelaher
- Centre for Health Policy, 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
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Schaaf M, Warthin C, Freedman L, Topp SM. The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability. BMJ Glob Health 2021; 5:bmjgh-2020-002296. [PMID: 32546585 PMCID: PMC7299037 DOI: 10.1136/bmjgh-2020-002296] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022] Open
Abstract
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.
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Affiliation(s)
| | - Caitlin Warthin
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lynn Freedman
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
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Mubin N, Bin Abdul Baten R, Jahan S, Zohora FT, Chowdhury NM, Faruque GM. Cancer related knowledge, attitude, and practice among community health care providers and health assistants in rural Bangladesh. BMC Health Serv Res 2021; 21:191. [PMID: 33653315 PMCID: PMC7927368 DOI: 10.1186/s12913-021-06202-z] [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: 11/16/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cancer remains one of the primary causes of death in Bangladesh. The success of cancer control in rural areas depends on the ability of the health care system and workforce to identify and manage cases properly at early stages. Community Health Workers (CHW) can play a vital role in this process. The present study aims to assess cancer related Knowledge, Attitude, and Practice (KAP) among 2 categories of CHWs - Community Health Care Providers (CHCP) and Health Assistants (HA) in rural Bangladesh. METHODS A descriptive cross-sectional study was conducted using a self-administered questionnaire from July 2019 to June 2020. Multi-stage sampling technique was used to determine the sample. One Upazilla Health Complex (UHC) from each of the eight administrative divisions of Bangladesh were randomly chosen as study sites, from which 325 CHCPs and HAs were in the final sample. Multivariate logistic regression models were developed to determine the association between KAP scores and demographic variables. RESULTS Our study shows that a modest number of respondents scored above average in the knowledge (54.15%), attitude (58.15%), and practice (65.54%) sections. Majority CHCPs (90.91%) and HAs (96.06%) did not receive govt. training on cancer. Only 20.71% HAs and 25.2% CHCPs knew about the availability of cancer treatment options in Bangladesh. Uncertainty about the availability of relevant treatments or vaccinations at public facilities was also high. Having cancer in the family, income, duration of employment and workplace locations were important predictors of cancer related KAP scores. CONCLUSION Healthcare workforce's knowledge gap and unfavorable attitude towards cancer may result in poor delivery of care at the rural level. For many people in rural areas, CHCPs and HAs are the first point of contact with the healthcare system and thus effective cancer control strategies must consider them as key stakeholders. Targeted training programs must be adopted to address the cancer related KAP gaps among CHCPs and HAs.
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Affiliation(s)
- Nazirum Mubin
- Department of Radiotherapy, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | | | | | - Fatema Tuz Zohora
- Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Naim Mahmud Chowdhury
- Department of Oral and Maxillofacial Surgery, Chhattogram International Dental College, Chittagong, Bangladesh
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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.
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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
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Topp SM, Carbone NB, Tseka J, Kamtsendero L, Banda G, Herce ME. " Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi. BMJ Glob Health 2020; 5:e002220. [PMID: 32561513 PMCID: PMC7304641 DOI: 10.1136/bmjgh-2019-002220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. METHODS We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2-4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. RESULTS Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. CONCLUSION PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | | | | | | | - Godfrey Banda
- University of North Carolina Project, Lilongwe, Malawi
| | - Michael E Herce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel HIll, North Carolina, USA
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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Sarma H, Jabeen I, Luies SK, Uddin MF, Ahmed T, Bossert TJ, Banwell C. Performance of volunteer community health workers in implementing home-fortification interventions in Bangladesh: A qualitative investigation. PLoS One 2020; 15:e0230709. [PMID: 32236114 PMCID: PMC7112190 DOI: 10.1371/journal.pone.0230709] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 03/06/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION BRAC, an international development organisation based in Bangladesh, uses female volunteer community health workers called Shasthya Shebika (SS), who receive small incentives to implement its home-fortification interventions at the community level. This paper examines the individual, community and BRAC work environment factors that exert an influence on the performance of SS. METHODS This qualitative study was conducted between the period of June 2014 to December 2016 as part of a larger evaluation of BRAC's home-fortification programme. Data were collected through in-depth interviews, focus group discussions, and key informant interviews and analysed thematically. The participants were SS and their supervisors working for BRAC, caregivers of children aged 6-59 months, husbands of SS, village doctors, and Upazila Health and Family Planning Officers. RESULTS Younger, better educated and more experienced SS with positive self-efficacy were perceived to have performed better than their peers. Social and community factors, such as community recognition of the SS's services, social and religious norms, family support, and household distance, also affected the performance of the SS. There were several challenges at the programme and organisational level that needed to be addressed, including appropriate recruitment, timely basic training and income-generation guidance for the SS. CONCLUSION BRAC's volunteer SS model faces challenges at individual, community, programme and organisational level. Importantly, BRAC's SS require a living wage to earn essential income for their family. Considering the current socio-cultural and economic context of Bangladesh, BRAC may need to revise the existing volunteer SS model to ensure that SS receive an adequate income so that they can devote themselves to implementing its home-fortification intervention.
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Affiliation(s)
- Haribondhu Sarma
- Research School of Population Health, College of Health and Medicine, The Australian National University, Acton, ACT, Australia
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, Bangladesh
- * E-mail:
| | - Ishrat Jabeen
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, Bangladesh
| | - Sharmin Khan Luies
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, Bangladesh
| | - Md. Fakhar Uddin
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, Bangladesh
| | - Thomas J. Bossert
- The Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Cathy Banwell
- Research School of Population Health, College of Health and Medicine, The Australian National University, Acton, ACT, Australia
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Factors associated with home visits by volunteer community health workers to implement a home-fortification intervention in Bangladesh: a multilevel analysis. Public Health Nutr 2020; 24:s23-s36. [PMID: 31983364 PMCID: PMC8042574 DOI: 10.1017/s1368980019003768] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective: BRAC, an international development organization based in Bangladesh, engages community health workers called Shasthya Shebikas (SS) to implement home fortification of foods with micronutrient powders (MNP). We identified factors associated with home visits by SS, at different levels of the BRAC programme-delivery hierarchy, to implement home-fortification interventions. Design: We conducted a cross-sectional survey, semi-structured interviews, and collected programme-related data from sub-districts included in the caregiver survey of BRAC’s home-fortification programme and performed multilevel logistic regression modelling to investigate factors associated with home visits by SS. Settings: Sixty-eight sub-districts in Bangladesh. Participants: Caregivers of children aged 6–59 months (n 1408) and BRAC’s SS (n 201). Results: Households with older children (0·55; 0·42, 0·72; P < 0·001) and located >300 m from the SS’s house (0·67; 0·50, 0·89; P = 0·006) were less likely to have been visited by the SS, whereas those with caregivers who had ≥5 years of schooling (1·53; 1·10, 2·12; P = 0·011) were more likely to have been visited by the SS (adjusted OR; 95 % CI). Households in the catchment area of older SS aged >50 years (0·44; 0·21, 0·90; P = 0·025) were less likely to have been visited by the SS, whereas those with SS who received incentives of >800 BDT (3·00; 1·58, 5·58; P = 0·001) were more likely to have been visited by the SS (adjusted OR; 95 % CI). Conclusions: The number of home visits is a function of the characteristics of SS, factors that characterize the households they serve and characteristics of their organizational context, particularly to implement home fortification of foods with MNP.
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Rahimi A, Kassam R, Dang Z, Sekiwunga R. Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study. Pharm Pract (Granada) 2019; 17:1622. [PMID: 31897260 PMCID: PMC6935545 DOI: 10.18549/pharmpract.2019.4.1622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/27/2019] [Indexed: 11/17/2022] Open
Abstract
Objective: A qualitative study was conducted to gain insight into challenges reported by
Butaleja households during a previous household survey. Specifically, this
paper discusses heads of households’ and caregivers’
perceptions of challenges they face when seeking care for their very young
children with fever presumed to be malaria. Methods: Eleven focus groups (FGs) were carried out with household members (five with
heads of households and six with household caregivers) residing in five
sub-counties located across the district. Purposive sampling was used to
ensure the sample represented the religious diversity and geographical
distance from the peri-urban center of the district. Each FG consisted of
five to six participants. The FGs were conducted at a community centre by
two pairs of researchers residing in the district and who were fluent in
both English and the local dialect of Lunyole. The discussions were
recorded, translated, and transcribed. Transcripts were reviewed and coded
with the assistance of QDA Miner (version 4.0) qualitative data management
software, and analyzed using thematic content analysis. Results: The FG discussions identified four major areas of challenges when managing
acute febrile illness in their child under the age of five with presumed
malaria (1) difficulties with getting to public health facilities due to
long geographical distances and lack of affordable transportation; (2) poor
service once at a public health facility, including denial of care, delay in
treatment, and negative experiences with the staff; (3) difficulties with
managing the child’s illness at home, including challenges with
keeping home-stock medicines and administering medicines as prescribed; and
(4) constrained to use private outlets despite their shortcomings. Conclusions: Future interventions may need to look beyond the public health system to
improve case management of childhood malaria at the community level in rural
districts such as Butaleja. Given the difficulties with accessing quality
private health outlets, there is a need to partner with the private sector
to explore feasible models of community-based health insurance programs and
expand the role of informal private providers.
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Affiliation(s)
- Asa Rahimi
- BSc (Hons). Faculty of Medicine, University of British Columbia. Vancouver, BC (Canada).
| | - Rosemin Kassam
- BSc Pharm, ACPR, PharmD, PhD. Professor. School of Population and Public Health, Faculty of Medicine, University of British Columbia. Vancouver, BC (Canada).
| | - Zhong Dang
- BSc MBIM. Research Assistant. School of Population and Public Health, Faculty of Medicine, University of British Columbia. Vancouver, BC (Canada).
| | - Richard Sekiwunga
- MSc PRH. Scientist. Child Health and Development Centre, School of Medicine, Makerere University, Kampala (Uganda).
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Franz B, Murphy JW. What role should philosophy play in community-based health services? J Eval Clin Pract 2019; 25:970-976. [PMID: 31037795 DOI: 10.1111/jep.13148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/24/2019] [Accepted: 03/28/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Berkeley Franz
- Department of Social Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - John W Murphy
- Department of Sociology, University of Miami, Coral Gables, Florida
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Borst RAJ, Hoekstra T, Muhangi D, Jonker I, Kok MO. Reaching rural communities through 'Healthy Entrepreneurs': a cross-sectional exploration of community health entrepreneurship's role in sexual and reproductive health. Health Policy Plan 2019; 34:676-683. [PMID: 31774511 PMCID: PMC6880333 DOI: 10.1093/heapol/czz091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2019] [Indexed: 11/19/2022] Open
Abstract
The purpose of the current study was to explore the association between community health entrepreneurship and the sexual and reproductive health status of rural households in West-Uganda. We collected data using digital surveys in a cluster-randomized cross-sectional cohort study. The sample entailed 1211 household members from 25 randomly selected villages within two subcounties, of a rural West-Ugandan district. The association between five validated sexual and reproductive health outcome indicators and exposure to community health entrepreneurship was assessed using wealth-adjusted mixed-effects logistic regression models. We observed that households living in an area where community health entrepreneurs were active reported more often to use at least one modern contraceptive method [odds ratios (OR): 2.01, 95% CI: 1.30-3.10] had more knowledge of modern contraceptive methods (OR: 7.75, 95% CI: 2.81-21.34), knew more sexually transmitted infections (OR: 1.86, 95% CI: 1.14-3.05), and mentioned more symptoms of sexually transmitted infections (OR: 1.83, 95% CI: 1.18-2.85). The association between exposure to community health entrepreneurship and communities' comprehensive knowledge of HIV/AIDS was more ambiguous (OR: 1.27, 95% CI: 0.97-1.67). To conclude, households living in areas where community health entrepreneurs were active had higher odds on using modern contraceptives and had more knowledge of modern contraceptive methods, sexually transmitted infections and symptoms of sexually transmitted infections. This study provides the first evidence supporting the role of community health entrepreneurship in providing rural communities with sexual and reproductive health care.
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Affiliation(s)
- Robert A J Borst
- Erasmus School of Health Policy & Management, Health Care Governance, Erasmus University Rotterdam, DR Rotterdam, The Netherlands
| | - Trynke Hoekstra
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, De Boelelaan 1085, HV, Amsterdam, The Netherlands
| | - Denis Muhangi
- Department of Social Work and Social Administration, Makerere University, Kampala, Uganda
| | - Isis Jonker
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, De Boelelaan 1085, HV, Amsterdam, The Netherlands
| | - Maarten Olivier Kok
- Erasmus School of Health Policy & Management, Health Care Governance, Erasmus University Rotterdam, DR Rotterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, De Boelelaan 1085, HV, Amsterdam, The Netherlands
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Rafiq MY, Wheatley H, Mushi HP, Baynes C. Who are CHWs? An ethnographic study of the multiple identities of community health workers in three rural Districts in Tanzania. BMC Health Serv Res 2019; 19:712. [PMID: 31638989 PMCID: PMC6802175 DOI: 10.1186/s12913-019-4563-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 09/26/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Numerous studies have examined the role of community health workers (CHWs) in improving the delivery of health services and accelerating progress towards national and international development goals. A limited but growing body of studies have also explored the interactions between CHWs' personal, communal and professional identities and the implications of these for their profession. CHWs possess multiple, overlapping roles and identities, which makes them effective primary health care providers when properly supported with adequate resources, but it also limits their ability to implement interventions that only target certain members of their community, follow standard business working days and hours. In some situations, it even prevents them from performing certain duties when it comes to sensitive topics such as family planning. METHODS To understand the multiple identities of CHWs, a mixture of qualitative and ethnographic methods was utilized, such as participant observation, open-ended and semi-structured interviews, and focus group discussions with CHWs, their supervisors, and their clients. The observation period began in October 2013 and ended in June 2014. This study was based on implementation research conducted by the Connect Project in Rufiji, Ulanga and Kilombero Districts in Tanzania and aimed to understand the role of CHWs in the provision of maternal and child health services in rural areas. RESULTS To our knowledge, this was the first study that employed an ethnographic approach to examine the relationship between personal, communal and professional identities, and its implications for CHWs' work in Tanzania. Our findings suggest that it is difficult to distinguish between personal and professional identities among CHWs in rural areas. Important aspects of CHW services such as personalization, access, and equity of health services were influenced by CHWs' position as local agents. However, the study also found that their personal identity sometimes inhibited CHWs in speaking about issues related to family planning and sexual health. Being local, CHWs were viewed according to the social norms of the area that consider the gender and age of each worker, which tended to constrain their work in family planning and other areas. Furthermore, the communities welcomed and valued CHWs when they had curative medicines; however, when medical stocks were delayed, the community viewed the CHWs with suspicion and disinterest. Community members who received curative services from CHWs also tended to become more receptive to their preventative health care work. CONCLUSION Although CHWs' multiple roles constrained certain aspects of their work in line with prevalent social norms, overall, the multiple roles they fulfilled had a positive effect by keeping CHWs embedded in their community and earned them trust from community members, which enhanced their ability to provide personalized, equitable and relevant services. However, CHWs needed a support system that included functional supply chains, supervision, and community support to help them retain their role as health care providers and enabled them to provide curative, preventative, and referral services.
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Affiliation(s)
| | | | | | - Colin Baynes
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania
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Bellas HC, Jatobá A, Bulhões B, Koster I, Arcuri R, Burns C, Grindrod K, de Carvalho PVR. Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas. J Community Health 2019; 44:569-576. [DOI: 10.1007/s10900-019-00657-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mehta R, Martorell R, Chaudhuri I, Girard AW, Ramakrishnan U, Verma P, Kekre P, Srikantiah S, Young MF. Use of monitoring data to improve implementation of a home fortification program in Bihar, India. MATERNAL AND CHILD NUTRITION 2018; 15:e12753. [PMID: 30426653 PMCID: PMC6617994 DOI: 10.1111/mcn.12753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
This paper describes the use of program‐monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6–18 months in Bihar, India. Communities (n = 70; reaching over 10,000 children) were randomized to receive either counselling on infant and young child feeding or both counselling and MNPs. Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real‐time program data allowed for recognition of key program issues and decision‐making to enhance program implementation.
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Affiliation(s)
- Rukshan Mehta
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia
| | - Reynaldo Martorell
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Amy Webb Girard
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Usha Ramakrishnan
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Priya Kekre
- The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Melissa F Young
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia.,The Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Hills AP, Misra A, Gill JMR, Byrne NM, Soares MJ, Ramachandran A, Palaniappan L, Street SJ, Jayawardena R, Khunti K, Arena R. Public health and health systems: implications for the prevention and management of type 2 diabetes in south Asia. Lancet Diabetes Endocrinol 2018; 6:992-1002. [PMID: 30287104 DOI: 10.1016/s2213-8587(18)30203-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 02/07/2023]
Abstract
Many non-communicable chronic diseases, including type 2 diabetes, are highly prevalent, costly, and largely preventable. The prevention and management of type 2 diabetes in south Asia requires a combination of lifestyle changes and long-term health-care management. However, public health and health-care systems in south Asian countries face serious challenges, including the need to provide services to many people with inadequate resources, and substantial between-population and within-population inequalities. In this Series paper, we explore the importance and particular challenges of public health and health systems in south Asian countries (Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka) with respect to the provision of culturally appropriate lifestyle modification to prevent and manage diabetes, especially in resource-poor settings. Effective primary prevention strategies are urgently needed to counter risk factors and behaviours preconception, in utero, in infancy, and during childhood and adolescence. A concerted focus on education, training, and capacity building at the community level would ensure the more widespread use of non-physician care, including community health workers. Major investment from governments and other sources will be essential to achieve substantial improvements in the prevention and management of type 2 diabetes in the region.
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Affiliation(s)
- Andrew P Hills
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia.
| | - Anoop Misra
- Fortis C-DOC Centre of Excellence for Diabetes, Metabolic Diseases, and Endocrinology, New Delhi, India; National Diabetes, Obesity, and Cholesterol Foundation, New Delhi, India; Diabetes Foundation (India), New Delhi, India
| | - Jason M R Gill
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Nuala M Byrne
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
| | - Mario J Soares
- School of Public Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Ambady Ramachandran
- India Diabetes Research Foundation & Dr A Ramachandran's Diabetes Hospitals, Guindy, Chennai, India
| | | | - Steven J Street
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
| | - Ranil Jayawardena
- Department of Physiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
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Roesler A, Smithers LG, Winichagoon P, Wangpakapattanawong P, Moore V. Health Workers' and Villagers' Perceptions of Young Child Health, Growth Monitoring, and the Role of the Health System in Remote Thailand. Food Nutr Bull 2018; 39:536-548. [PMID: 30419755 DOI: 10.1177/0379572118808632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In Thailand, despite widespread improvements in child nutrition, stunting is still highly prevalent among northern hill tribe children. OBJECTIVE To understand how villagers and health workers (volunteers and officials) gauge health of children younger than 5 years, whether growth monitoring is salient, and the relationships of villagers with the health system in this remote location. METHODS Qualitative research was undertaken with 8 hill tribe villages. A workshop on infant and young child health and nutrition was held with 8 village health volunteers, 2 per village, selected by a public health officer. In-depth interviews were conducted with 20 villagers and 2 volunteers who had children 0 to 5 years. Eight other health workers were also interviewed. All dialogue was conducted in Thai through bilingual facilitators and recorded, transcribed, and translated into English. Transcripts were coded and analyzed thematically within and across participant groups. RESULTS Overall, villagers considered strength and independence of children to be hallmarks of health; the size of children featured rarely. Volunteers did not perceive local benefits of growth monitoring, and the extent of child malnutrition was unclear to them. Nutrition counseling was seldom mentioned by villagers or health workers. Across all accounts, and considering silences, relationships of villagers with the health system seemed fragile. CONCLUSION Villagers understand child health in terms of functional abilities rather than size. Volunteer health workers in this remote location have limited resources and support. Together this helps explain why, against a background of poverty and food insecurity, growth monitoring does not translate to improvements in child nutrition.
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Affiliation(s)
- Anna Roesler
- 1 School of Public health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa G Smithers
- 1 School of Public health, The University of Adelaide, Adelaide, South Australia, Australia
| | | | - Prasit Wangpakapattanawong
- 3 The Knowledge Support Center for the Greater Mekong Sub-region (KSC-GMS), Chiang Mai University, Chiang Mai, Thailand.,4 World Agroforestry Centre (ICRAF), Chiang Mai University, Chiang Mai, Thailand
| | - Vivienne Moore
- 1 School of Public health, The University of Adelaide, Adelaide, South Australia, Australia.,5 Robinson Research Institute, University of Adelaide, Adelaide, Australia
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Jigssa HA, Desta BF, Tilahun HA, McCutcheon J, Berman P. Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions. HUMAN RESOURCES FOR HEALTH 2018; 16:57. [PMID: 30409189 PMCID: PMC6225677 DOI: 10.1186/s12960-018-0319-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 09/28/2018] [Indexed: 05/30/2023]
Abstract
BACKGROUND The use of community health workers (CHWs) has been considered as one of the strategies to address the growing shortage of health workers, predominantly in low-income countries. They are playing a pivotal role in lessening health disparities through improving health outcomes for underserved populations. Yet, little is known about what factors motivate and drive them to continue working as CHWs. In this study, we aimed to examine factors contributing to the motivation of volunteer CHWs (vCHWs) in Ethiopia currently known as one-to-five network leaders (1to5NLs) and explore variations between attributes of social and work-related determinants. METHOD We conducted a cross-sectional study in four selected woredas (the second lowest administrative structure in Ethiopia, and similar to a district) of Oromia and Tigray regions and interviewed 786 1to5NLs. The effects of each motivational factor were explored using percentage of respondents who agreed and strongly agreed to each of them and Mann-Whitney U test. RESULTS Individual, community, and health system factors contributed to the motivation of 1to5NLs in this study. Intrinsic desire to have a good status in the community as a result of their volunteer service (81.86%) followed by a commitment to serve the community (81.61%) and to gain satisfaction by accomplishing something worthwhile to the community (81.61%) were some of the factors motivating 1to5NLs in our study. Despite these motivational items, factors such as lack of career development (51.47%), unclear health development army guideline (59.26%), limited supervision and support (62.32%), and lack of recognition and appreciation of accomplishments (63.22%) were the factors negatively affecting motivation of 1to5NLs. Lack of career development, limited supervision and support, and lack of recognition and appreciation of accomplishments were significantly varied between attributes of educational level, marital status, service year as 1to5NLs, and previous volunteer engagement (at P < 0.05). CONCLUSION Findings of our study indicated that non-financial incentives such as the creation of career development models is the key to motivating and retaining CHWs where they are not receiving stipends. Sustainability of CHW program should consider exploring enhanced innovations to strengthen supportive supervision, development of better mechanisms to publicize the role of CHWs, and improvement of recognition and appreciation schemes for CHWs' efforts and accomplishments.
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Affiliation(s)
- Habtamu Abdissa Jigssa
- International Division, John Snow Research and Training Institute, Inc., Addis Ababa, Ethiopia
- John Snow Research and Training Institute, Inc., Fenot Project, Bole Sub City, Woreda 03/05, House No. 2347, PO Box 1988, 1250 Addis Ababa, Ethiopia
| | - Binyam Fekadu Desta
- International Division, John Snow Research and Training Institute, Inc., Addis Ababa, Ethiopia
| | - Hibret Alemu Tilahun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA United States of America
| | - Jen McCutcheon
- International Division, John Snow Research and Training Institute, Inc., Addis Ababa, Ethiopia
| | - Peter Berman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA United States of America
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Abstract
Background The lack of primary healthcare integration has been identified as one of the main limits to programs’ efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met for its achievement: 1) developing a “crosswise approach” to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors. Main body The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project (2011–2014) evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions. Conclusions In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions.
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Affiliation(s)
- Thomas Druetz
- Department of Tropical Medicine, Tulane University, 1440 Canal St, New Orleans, LA, USA.
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Hunter BM. Brokerage in commercialised healthcare systems: A conceptual framework and empirical evidence from Uttar Pradesh. Soc Sci Med 2018. [PMID: 29524868 DOI: 10.1016/j.socscimed.2018.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In many contexts there are a range of individuals and organisations offering healthcare services that differ widely in cost, quality and outcomes. This complexity is exacerbated by processes of healthcare commercialisation. Yet reliable information on healthcare provision is often limited, and progress to and through the healthcare system may depend on knowledge drawn from prior experiences, social networks and the providers themselves. It is in these contexts that healthcare brokerage emerges and third-party actors facilitate access to healthcare. This article presents a novel framework for studying brokerage of access to healthcare, and empirical evidence on healthcare brokerage in urban slums in Lucknow, Uttar Pradesh. The framework comprises six areas of interest that have been derived from sociological and political science literature on brokerage. A framework approach was used to group observational and interview data into six framework charts (one for each area of interest) to facilitate close thematic analysis. A cadre of women in Lucknow's urban slums performed healthcare brokerage by encouraging use of particular healthcare services, organising travel, and mediating communications and fee negotiations with providers. The women emphasised their personal role in facilitating access to care and encouraged dependency on their services by withholding information from users. They received commission payments from healthcare programmes, and sometimes from users and hospitals as well, but were blamed for issues beyond their control. Disruption to their ability to facilitate low-cost healthcare meant some women lost their positions as brokers, while others adapted by leveraging old and new relationships with hospital managers. Brokerage analysis reveals how people capitalise on the complexity of healthcare systems by positioning themselves as intermediaries. Commercialised healthcare systems offer a fertile environment for such behaviours, which can undermine attainment of healthcare entitlements and exacerbate inequities in healthcare access.
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Affiliation(s)
- Benjamin M Hunter
- King's College London, Department of International Development, Strand Campus, London WC2R 2LS, UK.
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Chol C, Negin J, Garcia-Basteiro A, Gebrehiwot TG, Debru B, Chimpolo M, Agho K, Cumming RG, Abimbola S. Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990-2015: a literature review. Glob Health Action 2018; 11:1517931. [PMID: 30270772 PMCID: PMC7011843 DOI: 10.1080/16549716.2018.1517931] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/23/2018] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades - including 13 wars during 1990-2015 - than any other part of the world, and this has had an adverse effect on health systems in the region. OBJECTIVE To understand the best health system practices in five SSA countries that experienced wars during 1990-2015, and yet managed to achieve a maternal mortality reduction - equal to or greater than 50% during the same period - according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Maternal mortality is a death of a woman during pregnancy, or within 42 days after childbirth - measured as maternal mortality ratio (MMR) per 100,000 live births. DESIGN We conducted a selective literature review based on a framework that drew upon the World Health Organisation's (WHO) six health system building blocks. We searched seven databases, Google Scholar as well as conducting a manual search of sources in articles' reference lists - restricting our search to articles published in English. We searched for terms related to maternal healthcare, the WHO six health system building blocks, and names of the five countries. RESULTS Our study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms. CONCLUSION Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars. Our findings provide insight from five war-affected SSA countries which could inform policy. However, since few studies have been conducted concerning this topic, our findings require further research to inform policy, and to help countries rebuild and maintain their health systems resilience.
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Affiliation(s)
- Chol Chol
- School of Public Health, Faculty of Medicine and Health, the University of Sydney, Sydney, Australia
| | - Joel Negin
- School of Public Health, Faculty of Medicine and Health, the University of Sydney, Sydney, Australia
| | | | | | - Berhane Debru
- Research and Human Resource Development, Ministry of Health, Asmara, The State of Eritrea
| | - Maria Chimpolo
- Faculdade de Medicina, Universidade Agostinho Neto, Luanda, Angola
| | - Kingsley Agho
- School of Science and Health, Western Sydney University, Sydney, Australia
| | - Robert G Cumming
- School of Public Health, Faculty of Medicine and Health, the University of Sydney, Sydney, Australia
| | - Seye Abimbola
- School of Public Health, Faculty of Medicine and Health, the University of Sydney, Sydney, Australia
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Ingram M, Chang J, Kunz S, Piper R, de Zapien JG, Strawder K. Women's Health Leadership to Enhance Community Health Workers as Change Agents. Health Promot Pract 2017; 17:391-9. [PMID: 27440785 DOI: 10.1177/1524839916637047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives A community health worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. While natural leadership may incline individuals to the CHW profession, they do not always have skills to address broad social issues. We describe evaluation of the Women's Health Leadership Institute (WHLI), a 3-year training initiative to increase the capacity of CHWs as change agents. Methods Pre-/postquestionnaires measured the confidence of 254 participants in mastering WHLI leadership competencies. In-depth interviews with CHW participants 6 to 9 months after the training documented application of WHLI competencies in the community. A national CHW survey measured the extent to which WHLI graduates used leadership skills that resulted in concrete changes to benefit community members. Multivariate logistic regressions controlling for covariates compared WHLI graduates' leadership skills to the national sample. Results Participants reported statistically significant pre-/postimprovements in all competencies. Interviewees credited WHLI with increasing their capacity to listen to others, create partnerships, and initiate efforts to address community needs. Compared to a national CHW sample, WHLI participants were more likely to engage community members in attending public meetings and organizing events. These activities led to community members taking action on an issue and a concrete policy change. Conclusions Leadership training can increase the ability of experienced CHWs to address underlying issues related to community health across different types of organizational affiliations and job responsibilities.
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Affiliation(s)
| | | | - Susan Kunz
- Mariposa Community Health Center, Nogales, AZ, USA
| | - Rosie Piper
- Mariposa Community Health Center, Nogales, AZ, USA
| | | | - Kay Strawder
- Office on Women's Health, U.S. Department of Health and Human Services, San Francisco, CA, USA
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30
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Ballard M, Montgomery P. Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries. BMJ Open 2017; 7:e014216. [PMID: 29074507 PMCID: PMC5665298 DOI: 10.1136/bmjopen-2016-014216] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To systematically review and critically appraise the evidence for the effects of interventions to improve the performance of community health workers (CHWs) for community-based primary healthcare in low- and middle-income countries. DESIGN Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS 19 electronic databases were searched with a highly sensitive prespecified strategy and the grey literature examined, completed July 2016. Randomised controlled trials evaluating interventions to improve CHW performance in low- and middle-income countries were included and appraised for risk of bias. Outcomes were biological and behavioural patient outcomes (primary), use of health services, quality of care provided by CHWs and CHW retention (secondary). RESULTS Two reviewers screened 8082 records; 14 evaluations were included. Due to heterogeneity and lack of clear outcome data, no meta-analysis was conducted. Results were presented in a narrative summary. The review found one study showing no effect on the biological outcomes of interest, though these moderate quality data may not be indicative of all biological outcomes. It also found moderate quality evidence of the efficacy of performance improvement interventions for (1) improving behavioural outcomes for patients, (2) improving use of services by increasing the absolute number of patients who access services and, perhaps, better identifying those who would benefit from such services and (3) improving CHW quality of care in terms of upstream measures like completion of prescribed activities and downstream measures like adherence to treatment protocols. Nearly half of studies were compound interventions, making it difficult to isolate the effects of individual performance improvement intervention components, though four specific strategies pertaining to recruitment, supervision, incentivisation and equipment were identified. CONCLUSIONS Variations in recruitment, supervision, incentivisation and equipment may improve CHW performance. Practitioners should, however, assess the relevance and feasibility of these strategies in their health setting prior to implementation. Component selection experiments on a greater range of interventions to improve performance ought to be conducted.
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Affiliation(s)
- Madeleine Ballard
- Centre for Evidence-Based Intervention, University of Oxford, Oxford, UK
| | - Paul Montgomery
- Department of Social Policy and Social Work, University of Birmingham, Birmingham, UK
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31
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Kitutu FE, Kalyango JN, Mayora C, Selling KE, Peterson S, Wamani H. Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study. Malar J 2017; 16:425. [PMID: 29061148 PMCID: PMC5654057 DOI: 10.1186/s12936-017-2072-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/17/2017] [Indexed: 11/17/2022] Open
Abstract
Background Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda’s Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda. Methods From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller–care-seeker encounters in intervention drug shops. Results The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2–107.2), 65.5% (95% CI 51.6–79.4) and 31.4% (95% CI 1.6–61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, − 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops. Conclusions The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2072-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Freddy Eric Kitutu
- Pharmacy Department, Makerere University College of Health Sciences, Kampala, Uganda. .,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda. .,International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden.
| | - Joan Nakayaga Kalyango
- Pharmacy Department, Makerere University College of Health Sciences, Kampala, Uganda.,Clinical Epidemiology and Biostatistics Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chrispus Mayora
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,School of Public Health, University of Witwatersrand, 27 St. Andrews Road, Parktown, Johannesburg, 2193, South Africa
| | - Katarina Ekholm Selling
- International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
| | - Stefan Peterson
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden.,Health Section, UNICEF, 3 UN Plaza, New York, NY, 10017, USA
| | - Henry Wamani
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Chikaphupha KR, Kok MC, Nyirenda L, Namakhoma I, Theobald S. Motivation of health surveillance assistants in Malawi: A qualitative study. Malawi Med J 2017; 28:37-42. [PMID: 27895826 DOI: 10.4314/mmj.v28i2.2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Motivation of health workers is a critical component of performance and is shaped by multiple factors. This study explored factors that influence motivation of health surveillance assistants (HSAs) in Malawi, with the aim of identifying interventions that can be applied to enhance motivation and performance of HSAs. METHODS A qualitative study capturing the perspectives of purposively selected participants was conducted in two districts: Salima and Mchinji. Participants included HSAs, health managers, and various community members. Data were collected through focus group discussions (n = 16) and in-depth interviews (n = 44). The study sample was comprised of 112 women and 65 men. Qualitative data analysis was informed by existing frameworks on factors influencing health worker motivation. RESULTS Our analysis identified five key themes shaping HSA motivation: salary, accommodation, human resource management, supplies and logistics, and community links. Each of these played out at different levels-individual, family, community, and organisational-with either positive or negative effects. Demotivating factors related primarily to the organisational level, while motivating factors were more often related to individual, family, and community levels. A lack of financial incentives and shortages of basic supplies and materials were key factors demotivating HSAs. Supervision was generally perceived as unsupportive, uncoordinated, and top-down. Most HSAs complained of heavy workload. Many HSAs felt further recognition and support from the Ministry of Health, and the development of a clear career pathway would improve their motivation. CONCLUSIONS Factors shaping motivation of HSAs are complex and multilayered; experiences at one level will impact other levels. Interventions are required to enhance HSA motivation, including strengthening the supervision system, developing career progression pathways, and ensuring clear and transparent incentives. HSAs have unique experiences, and there is need to hear and address these to better enable HSAs to cope with the challenging conditions they work in.
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Affiliation(s)
| | - Maryse C Kok
- Royal Tropical Institute, Amsterdam, the Netherlands
| | - Lot Nyirenda
- University of Livingstonia, Livingstonia, Malawi
| | - Ireen Namakhoma
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Sheikh K, Josyula LK, Zhang X, Bigdeli M, Ahmed SM. Governing the mixed health workforce: learning from Asian experiences. BMJ Glob Health 2017; 2:e000267. [PMID: 28589031 PMCID: PMC5435263 DOI: 10.1136/bmjgh-2016-000267] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/05/2017] [Accepted: 02/07/2017] [Indexed: 01/28/2023] Open
Abstract
Examination of the composition of the health workforce in many low and middle-income countries (LMICs) reveals deep-seated heterogeneity that manifests in multiple ways: varying levels of official legitimacy and informality of practice; wide gradation in type of employment and behaviour (public to private) and diverse, sometimes overlapping, systems of knowledge and variably specialised cadres of providers. Coordinating this mixed workforce necessitates an approach to governance that is responsive to the opportunities and challenges presented by this diversity. This article discusses some of these opportunities and challenges for LMICs in general, and illustrates them through three case studies from different Asian country settings.
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Affiliation(s)
- Kabir Sheikh
- Public Health Foundation of India, New Delhi, India
| | - Lakshmi K Josyula
- Previous affiliation: Indian Institute of Public Health, Hyderabad, Public Health Foundation of India; Present affiliation: The George Institute for Global Health, Hyderabad, India
| | - Xiulan Zhang
- China Institute of Health, School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Maryam Bigdeli
- Past: Alliance for Health Policy and Systems Research, WHO; Present: Department of Health Systems Governance, Policy and Aid Effectiveness, World Health Organization (WHO), Geneva, Switzerland
| | - Syed Masud Ahmed
- Centre of Excellence for UHC, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Baatiema L, Sumah AM, Tang PN, Ganle JK. Community health workers in Ghana: the need for greater policy attention. BMJ Glob Health 2016; 1:e000141. [PMID: 28588981 PMCID: PMC5321387 DOI: 10.1136/bmjgh-2016-000141] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/31/2016] [Accepted: 11/03/2016] [Indexed: 12/04/2022] Open
Abstract
From the 1970s to the 1990s, the WHO, United Nations and other agencies mooted the idea of formally training and recognising community health workers (CHWs) to complement efforts to improve primary healthcare delivery in low and middle income countries. Recently, CHWs have been recognised as important players in the achievement of the health-related Millennium Development Goals (MDGs). Despite this recognition, little understanding exists in Ghana about the activities of CHWs: who they are; how they are recruited; what they do; level of health policy support; contribution to healthcare delivery and the challenges they face. Based on a rapid scoping review of the existing literature, and our experience working in Ghana, this paper reflects on the role of CHWs in healthcare delivery in Ghana. We argue that CHWs have played critical roles in improving health service delivery and outcomes, including guinea worm eradication, expanded immunisation coverage, maternal and child health, and HIV/AIDS treatment and management. However, these achievements notwithstanding, CHWs face challenges which prevent them from being optimally productive, including capacity problems, neglect by the healthcare system, high attrition rates and inadequate supervision. Policymakers in Ghana therefore need to give increased attention to CHWs, provide remuneration for their activities, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities.
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Affiliation(s)
- Leonard Baatiema
- Integrated Social Development Centre, Tamale, Ghana
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, North Sydney, New South Wales, Australia
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Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. HUMAN RESOURCES FOR HEALTH 2016; 14:65. [PMID: 27784298 PMCID: PMC5081930 DOI: 10.1186/s12960-016-0163-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 10/10/2016] [Indexed: 05/21/2023]
Abstract
BACKGROUND There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years. This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period. METHODS A scoping review of publications on CHWs from 2005 to 2014 was conducted. Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC. Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria. These were coded in an Excel spreadsheet by year, type of publication (e.g. review, empirical), country, region, programmatic orientation (e.g. maternal-child health, HIV/AIDS, comprehensive) and CHW roles (e.g. prevention, treatment) and further analysed in Stata14. Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped. FINDINGS Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period. There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014. Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil). The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %). Only 17 % of the publications approached CHW roles in an integrated fashion. There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions. CONCLUSIONS The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action. This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes.
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Affiliation(s)
- Helen Schneider
- School of Public Health & SAMRC/UWC Health Services to Systems Unit, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town 7535 South Africa
| | - Dickson Okello
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town 7535 South Africa
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Palmer JJ, Gilbert A, Choy M, Blanchet K. Circumventing 'free care' and 'shouting louder': using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania. Health Res Policy Syst 2016; 14:68. [PMID: 27612454 PMCID: PMC5017067 DOI: 10.1186/s12961-016-0137-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 08/09/2016] [Indexed: 11/21/2022] Open
Abstract
Background Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable. Methods In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there. Results Practitioners in this region felt eye care was systemically neglected by government and therefore was ‘all under the NGOs’, but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain ‘sustainability funds’ to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for ‘free care’. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system. Conclusions Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs’ investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation. Electronic supplementary material The online version of this article (doi:10.1186/s12961-016-0137-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer J Palmer
- Department of Infectious Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom.,Centre of African Studies, School of Political and Social Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Alice Gilbert
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Michelle Choy
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, United Kingdom
| | - Karl Blanchet
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, United Kingdom.
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Community perceptions of behaviour change communication interventions of the maternal neonatal and child health programme in rural Bangladesh: an exploratory study. BMC Health Serv Res 2016; 16:389. [PMID: 27530405 PMCID: PMC4987986 DOI: 10.1186/s12913-016-1632-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 08/04/2016] [Indexed: 12/04/2022] Open
Abstract
Background This qualitative study explored community perceptions of the components of the behaviour change communication (BCC) intervention of the BRAC Improving Maternal, Neonatal and Child Survival (IMNCS) programme in rural Bangladesh. Methods Semi-structured interviews, key informant interviews, focus group discussions and informal group discussions were conducted to elicit community views on interpersonal communication (IPC), printed materials, entertainment education (EE) and mass media, specifically (a) acceptance of and challenges presented by different forms of media, (b) comprehensibility of terms; printed materials and entertainment education and (c) reported influence of BCC messages. Results IMNCS BCC interventions are well accepted by the community people. IPC is considered an essential aspect of everyday life and community members appreciate personal interaction with the BRAC community health workers. Printed materials assisted in comprehension and memorization of messages particularly when explained by community health workers (CHW) during IPC. Enactment of maternal, neonatal and child health (MNCH) narratives and traditional musical performances in EE helped to give deep insight into life’s challenges and the decision making that is inherent in pregnancy, childbirth and childcare. EE also improved memorization of the messages. Some limitations were identified in design of illustrations which hampered message comprehension. Some respondents were unable to differentiate between pregnancy, delivery and postpartum danger signs. Furthermore some women were afraid to view the illustrations of danger signs as they believed seeing that might be associated with the development of these complications in their own lives. Despite these barriers, participants stated that the IMNCS BCC interventions had influenced them to take health promoting decisions and seek MNCH services. Conclusions Community based maternal and newborn programmes should revise BCC interventions to strengthen IPC, using rigorously tested print materials as aids and stand-alone media. Messages about birth preparedness (especially savings), recognition of danger signs and immediate self-referral to biomedical health services should be carefully aligned and effectively delivered to women, men and older members of the community. Messaging should utilize gendered storyline and address the seasonal cycles of conception, birth, antenatal, post-natal care and childhood illnesses. Future research should identify how best to combine IPC, printed materials, traditional cultural forms, and incorporate use of social media and mass media in different field situations. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1632-y) contains supplementary material, which is available to authorized users.
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Masquillier C, Wouters E, Mortelmans D, van Wyk B, Hausler H, Van Damme W. HIV/AIDS Competent Households: Interaction between a Health-Enabling Environment and Community-Based Treatment Adherence Support for People Living with HIV/AIDS in South Africa. PLoS One 2016; 11:e0151379. [PMID: 26963257 PMCID: PMC4786154 DOI: 10.1371/journal.pone.0151379] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 02/27/2016] [Indexed: 02/06/2023] Open
Abstract
In the context of severe human resource shortages in HIV care, task-shifting and especially community-based support are increasingly being cited as potential means of providing durable care to chronic HIV patients. Socio-ecological theory clearly stipulates that-in all social interventions-the interrelatedness and interdependency between individuals and their immediate social contexts should be taken into account. People living with HIV/AIDS (PLWHA) seldom live in isolation, yet community-based interventions for supporting chronic HIV patients have largely ignored the social contexts in which they are implemented. Research is thus required to investigate such community-based support within its context. The aim of this study is to address this research gap by examining the way in which HIV/AIDS competence in the household hampers or facilitates community-based treatment adherence support. The data was analyzed carefully in accordance with the Grounded Theory procedures, using Nvivo 10. More specifically, we analyzed field notes from participatory observations conducted during 48 community-based treatment adherence support sessions in townships on the outskirts of Cape Town, transcripts of 32 audio-recorded in-depth interviews with PLWHA and transcripts of 4 focus group discussions with 36 community health workers (CHWs). Despite the fact that the CHWs try to present themselves as not being openly associated with HIV/AIDS services, results show that the presence of a CHW is often seen as a marker of the disease. Depending on the HIV/AIDS competence in the household, this association can challenge the patient's hybrid identity management and his/her attempt to regulate the interference of the household in the disease management. The results deepen our understanding of how the degree of HIV/AIDS competence present in a PLWHA's household affects the manner in which the CHW can perform his or her job and the associated benefits for the patient and his/her household members. In this respect, a household with a high level of HIV/AIDS competence will be more receptive to treatment adherence support, as the patient is more likely to allow interaction between the CHW and the household. In contrast, in a household which exhibits limited characteristics of HIV/AIDS competence, interaction with the treatment adherence supporter may be difficult in the beginning. In such a situation, visits from the CHW threaten the hybrid identity management. If the CHW handles this situation cautiously and the patient-acting as a gate keeper-allows interaction, the CHW may be able to help the household develop towards HIV/AIDS competence. This would have a more added value compared to a household which was more HIV/AIDS competent from the outset. This study indicates that pre-existing dynamics in a patient's social environment, such as the HIV/AIDS competence of the household, should be taken into account when designing community-based treatment adherence programs in order to provide long-term quality care, treatment and support in the context of human resource shortages.
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Affiliation(s)
- Caroline Masquillier
- Research Centre for Longitudinal and Life Course Studies (CELLO), University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Edwin Wouters
- Research Centre for Longitudinal and Life Course Studies (CELLO), University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
| | - Dimitri Mortelmans
- Research Centre for Longitudinal and Life Course Studies (CELLO), University of Antwerp, Antwerp, Belgium
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Adejumo AO, Azuogu B, Okorie O, Lawal OM, Onazi OJ, Gidado M, Daniel OJ, Okeibunor JC, Klinkenberg E, Mitchell EMH. Community referral for presumptive TB in Nigeria: a comparison of four models of active case finding. BMC Public Health 2016; 16:177. [PMID: 26905034 PMCID: PMC4763441 DOI: 10.1186/s12889-016-2769-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 01/22/2016] [Indexed: 11/10/2022] Open
Abstract
Background Engagement of communities and civil society organizations is a critical part of the Post-2015 End TB Strategy. Since 2007, many models of community referral have been implemented to boost TB case detection in Nigeria. Yet clear insights into the comparative TB yield from particular approaches have been limited. Methods We compared four models of active case finding in three Nigerian states. Data on presumptive TB case referral by community workers (CWs), TB diagnoses among referred clients, active case finding model characteristics, and CWs compensation details for 2012 were obtained from implementers and CWs via interviews and log book review. Self-reported performance data were triangulated against routine surveillance data to assess concordance. Analysis focused on assessing the predictors of presumptive TB referral. Results CWs referred 4–22 % of presumptive TB clients tested, and 4–24 % of the total TB cases detected. The annual median referral per CW ranged widely among the models from 1 to 48 clients, with an overall average of 13.4 referrals per CW. The highest median referrals (48 per CW/yr) and mean TB diagnoses (7.1/yr) per CW (H =70.850, p < 0.001) was obtained by the model with training supervision, and $80/quarterly payments (Comprehensive Quotas-Oriented model). The model with irregularly supervised, trained, and compensated CWs contributed the least to TB case detection with a median of 13 referrals per CW/yr and mean of 0.53 TB diagnoses per CW/yr. Hours spent weekly on presumptive TB referral made the strongest unique contribution (Beta = 0.514, p < 0.001) to explaining presumptive TB referral after controlling for other variables. Conclusion All community based TB case-finding projects studied referred a relative low number of symptomatic individuals. The study shows that incentivized referral, appropriate selection of CWs, supportive supervision, leveraged treatment support roles, and a responsive TB program to receive clients for testing were the key drivers of community TB case finding.
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Affiliation(s)
- A O Adejumo
- Department of Community Health and Primary Health Care, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.
| | - B Azuogu
- Department of Community Medicine, Ebonyi State University, Abakaliki, Nigeria
| | - O Okorie
- Abia State TB and Leprosy Control Programme, Umuahia, Abia, Nigeria
| | - O M Lawal
- Oyo State TB and Leprosy Control programme, Ibadan, Oyo, Nigeria
| | | | | | - O J Daniel
- Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun, Nigeria
| | - J C Okeibunor
- Department of Sociology/Anthropology, University of Nigeria, Nsukka, Enugu, Nigeria
| | - E Klinkenberg
- KNCV Tuberculosis Foundation, the Hague, The Netherlands.,Department of Global Health, Academic Medical Center, Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands
| | - E M H Mitchell
- KNCV Tuberculosis Foundation, the Hague, The Netherlands.,Department of Global Health, Academic Medical Center, Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands
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Baynes C, Semu H, Baraka J, Mushi H, Ramsey K, Kante AM, Phillips JF. An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania. Glob Public Health 2016; 12:1018-1032. [DOI: 10.1080/17441692.2015.1080750] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Colin Baynes
- Mailman School of Public Health, Columbia University, New York, USA
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Helen Semu
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | | | | | - Kate Ramsey
- Mailman School of Public Health, Columbia University, New York, USA
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Almamy Malick Kante
- Mailman School of Public Health, Columbia University, New York, USA
- Ifakara Health Institute, Dar es Salaam, Tanzania
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Ghesquiere AR, Pinto RM, Rahman R, Spector AY. Factors Associated with Providers' Perceptions of Mental Health Care in Santa Luzia's Family Health Strategy, Brazil. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 13:ijerph13010033. [PMID: 26703644 PMCID: PMC4730424 DOI: 10.3390/ijerph13010033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 11/02/2015] [Accepted: 11/05/2015] [Indexed: 11/17/2022]
Abstract
Brazil has a unique mental health care system, characterized by universal coverage delivered by interdisciplinary teams both in the community and in specialized centros de atenção psicossocial (CAPS-psychosocial care centers). Provision of patient-centered mental health care is an important principle of Brazilian mental health care, but this topic has not been well-studied. We analyzed data from a cross-sectional survey of 151 community health workers (CHWs), nurses, and physicians in Santa Luzia, Minas Gerais State, Brazil. Chi-squares, t-tests and multivariate regression analyses examined differences in socio-demographics, caseload, engagement in evidence-based practices (EBPs), and transdisciplinary collaboration between providers who reported providing high levels of patient-centered mental health care and those who did not. In multivariate regression models, components of transdisciplinary collaboration were significantly associated with providers' perceptions of patient-centered mental health care (p < 0.05). CHWs were also significantly more likely to report providing patient-centered care than physicians and nurses. EBP engagement and sociodemographics were not associated with perceptions. Results suggest that training efforts to improve patient-centered mental health care in Brazil could build upon CHWs' skills and focus on transdisciplinary collaboration. Findings may inform practice in other countries with similar health care systems.
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Affiliation(s)
- Angela R Ghesquiere
- Brookdale Center for Healthy Aging, Hunter College of the City University of New York, 2180 Third Ave, New York, NY 10035, USA.
| | - Rogerio M Pinto
- School of Social Work, University of Michigan, Room 3792 SSWB, 1080 S. University Ave., Ann Arbor, MI 48109, USA.
| | - Rahbel Rahman
- School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY 10027, USA.
| | - Anya Y Spector
- New York City Department of Health and Mental Hygiene, 42-09 28th St, Long Island City, NY 11101, USA.
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George A, Young M, Nefdt R, Basu R, Sylla M, Clarysse G, Bannicq MY, de Sousa A, Binkin N, Diaz T. Community health workers providing government community case management for child survival in sub-Saharan Africa: who are they and what are they expected to do? Am J Trop Med Hyg 2015; 87:85-91. [PMID: 23136282 PMCID: PMC3748527 DOI: 10.4269/ajtmh.2012.11-0757] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We describe community health workers (CHWs) in government community case management (CCM) programs for child survival across sub-Saharan Africa. In sub-Saharan Africa, 91% of 44 United Nations Children's Fund (UNICEF) offices responded to a cross-sectional survey in 2010. Frequencies describe CHW profiles and activities in government CCM programs (N = 29). Although a few programs paid CHWs a salary or conversely, rewarded CHWs purely on a non-financial basis, most programs combined financial and non-financial incentives and had training for 1 week. Not all programs allowed CHWs to provide zinc, use timers, dispense antibiotics, or use rapid diagnostic tests. Many CHWs undertake health promotion, but fewer CHWs provide soap, water treatment products, indoor residual spraying, or ready-to-use therapeutic foods. For newborn care, very few promote kangaroo care, and they do not provide antibiotics or resuscitation. Even if CHWs are as varied as the health systems in which they work, more work must be done in terms of the design and implementation of the CHW programs for them to realize their potential.
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Affiliation(s)
- Asha George
- *Address correspondence to Asha George, Bloomberg School of Public Health, John Hopkins University, 615 North Wolfe Street, Suite E-8146, Baltimore, MD 21205. E-mail:
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Datiko DG, Yassin MA, Tulloch O, Asnake G, Tesema T, Jamal H, Markos P, Cuevas LE, Theobald S. Exploring providers' perspectives of a community based TB approach in Southern Ethiopia: implication for community based approaches. BMC Health Serv Res 2015; 15:501. [PMID: 26553340 PMCID: PMC4638085 DOI: 10.1186/s12913-015-1149-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 10/16/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is increasing interest in the role of close-to-community providers in supporting universal health coverage, but questions remain about the best approaches to supporting and motivating these providers, and the optimal package they can deliver indifferent contexts and support required. We report on the experiences of different health providers involved in a community based intervention to support access to tuberculosis diagnosis and treatment in Southern Ethiopia. METHODS The aim of the study is to explore the experiences of health providers in delivering a community-based tuberculosis package in southern Ethiopia and to draw lessons for community-based programmes. A qualitative methodology was used. Methods included in-depth interviews (IDIs, n= 37) with all health provider groups: Community health promoters (CHPs), health extension workers (HEWs), district supervisors and laboratory technicians were undertaken to obtain a detailed understanding of the experiences of providers in the community based tuberculosis package. These were complemented with cadre specific focus group discussions (n= 3). We used the framework approach for qualitative analysis. RESULTS The key theme that emerged was the positive impact the community-based intervention had on vulnerable groups' access to diagnosis, care and treatment for tuberculosis. Providers found the positive feedback from, and visible impact on, communities very motivating. Other themes related to motivation and performance included supervision and support; learning new skills; team problem solving/ addressing challenges and incentives. Against the backdrop of the Ethiopian Health Extension Programme (HEP), HEWs were successfully able to take on new tasks (collecting sputum and preparing smears) with additional training and appropriate support from supervisors, laboratory technicians and CHPs. CONCLUSION All categories of providers were motivated by the high visible impact of the community-based intervention on poor and vulnerable communities and households. HEWs role in the community-based intervention was supported and facilitated through the structures and processes established within the community-based intervention and the broader nation-wide Health Extension Programme. Within community based approaches there is need to develop context embedded strategies to support, sustain and motivate this critical cadre who play a pivotal role in linking health systems and rural communities.
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Affiliation(s)
- Daniel G Datiko
- TB REACH Project, Sidama Zone, Hawassa, Ethiopia.
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Mohammed A Yassin
- Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
| | - Olivia Tulloch
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Girum Asnake
- TB REACH Project, Sidama Zone, Hawassa, Ethiopia.
| | | | - Habiba Jamal
- TB REACH Project, Sidama Zone, Hawassa, Ethiopia.
| | | | - Luis E Cuevas
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
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Rahmawati R, Bajorek B. A Community Health Worker-Based Program for Elderly People With Hypertension in Indonesia: A Qualitative Study, 2013. Prev Chronic Dis 2015; 12:E175. [PMID: 26469948 PMCID: PMC4611861 DOI: 10.5888/pcd12.140530] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction Hypertension is prevalent in the elderly, but treatment is often inadequate, particularly in developing countries. The objective of this study was to explore the role of a community-based program in supporting patients with hypertension in an Indonesian rural community. Methods A qualitative study comprising observation and in-depth interviews was conducted in an Integrated Health Service Post for the Elderly (IHSP-Elderly) program in Bantul district (Yogyakarta province). Eleven members of IHSP-Elderly program (ie, hypertensive patients), 3 community health workers (CHWs), and 1 district health staff member were interviewed to obtain their views about the role of the IHSP-Elderly program in hypertension management. Data were analyzed using thematic analysis. Results CHWs played a prominent role as the gatekeepers of health care in the rural community. In supporting hypertension management, CHWs served members of the IHSP-Elderly program by facilitating blood pressure checks and physical exercise and providing health education. Members reported various benefits, such as a healthier feeling overall, peer support, and access to affordable health care. Members felt that IHSP-Elderly program could do more to provide routine blood pressure screening and improve the process of referral to other health care services. Conclusion CHWs have the potential to liaise between rural communities and the wider health care system. Their role needs to be strengthened through targeted organizational support that aims to improve delivery of, and referral to, care. Further study is needed to identify the key factors for effective CHW-based programs in rural communities and the incorporation of these programs into the health care system.
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Affiliation(s)
- Riana Rahmawati
- School of Pharmacy, University of Technology Sydney, CB 01.13, PO Box 123, Broadway NSW 2007, Australia. . Dr Rahmawati is also affiliated with Pharmacology Department, Islamic University of Indonesia, Sleman, Yogyakarta, Indonesia
| | - Beata Bajorek
- Graduate School of Health, School of Pharmacy, University of Technology Sydney, Australia, and Department of Pharmacy, Royal North Shore Hospital, Sydney, Australia
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Tracing defaulters in HIV prevention of mother-to-child transmission programmes through community health workers: results from a rural setting in Zimbabwe. J Int AIDS Soc 2015; 18:20022. [PMID: 26462714 PMCID: PMC4604210 DOI: 10.7448/ias.18.1.20022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 08/29/2015] [Accepted: 09/08/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker–based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date. Methods We analyzed patient records of 1878 HIV-positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post-partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post-partum, cotrimoxazole (CTX) initiation at six weeks post-partum, and HIV testing at six weeks post-partum) before and after the introduction of CHW-DT in the project. Results Median maternal age was 27 years (inter-quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL3 (IQR 257 to 563). The covariate-adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96, p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06, p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42, p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01, p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93, p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection. Conclusions The CHW-DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post-natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource-limited settings can be as low as in resource-rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.
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Puett C, Alderman H, Sadler K, Coates J. 'Sometimes they fail to keep their faith in us': community health worker perceptions of structural barriers to quality of care and community utilisation of services in Bangladesh. MATERNAL & CHILD NUTRITION 2015; 11:1011-22. [PMID: 23941290 PMCID: PMC6860328 DOI: 10.1111/mcn.12072] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Community health workers (CHWs) have strong potential to extend health and nutrition services to underserved populations. However, CHWs face complex challenges when working within weak health systems and among communities with limited abilities to access and utilise CHW services. It is crucial to understand these challenges to improve programme support mechanisms. This study describes the results of qualitative investigations into CHW perceptions of barriers to quality of care among two groups of workers implementing community case management of acute respiratory infection, diarrhoea and severe acute malnutrition in southern Bangladesh. We explored systemic barriers to service delivery, pertaining to communities and health systems, which limited the usefulness and effectiveness of CHW services. Focus group discussions (n = 10) were conducted in March 2010. Discussions were analysed for themes related to CHWs' work challenges. Findings highlight several perceived barriers to effective service provision, including community poverty constraining uptake of recommended practices, irregular supplies of medicine from the health facility and poor quality of care for CHW referrals sent there. This study further documents interactions between demand-side and supply-side constraints including the influence of health system resource constraints on community trust in CHW services, and the influence of community resource constraints on the utilisation and effectiveness of CHW services. By documenting service delivery challenges from the perspective of the frontline workers themselves, this article contributes evidence to help identify appropriate support mechanisms for these workers, in order to develop scalable and sustainable CHW programmes in countries with under-resourced public health care infrastructure.
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Affiliation(s)
- Chloe Puett
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | - Harold Alderman
- International Food Policy Research Institute (IFPRI)Washington, DCUSA
| | - Kate Sadler
- Feinstein International CenterTufts UniversityMedfordMassachusettsUSA
| | - Jennifer Coates
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
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Turinawe EB, Rwemisisi JT, Musinguzi LK, de Groot M, Muhangi D, de Vries DH, Mafigiri DK, Pool R. Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion. HUMAN RESOURCES FOR HEALTH 2015; 13:73. [PMID: 26346431 PMCID: PMC4562111 DOI: 10.1186/s12960-015-0074-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 08/27/2015] [Indexed: 05/28/2023]
Abstract
BACKGROUND Community health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion. METHODS As part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members. RESULTS The VHT selection process created distrust, damaging the programme's legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community's members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work. CONCLUSION As the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.
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Affiliation(s)
| | | | | | | | | | | | | | - Robert Pool
- University of Amsterdam, Amsterdam, Netherlands.
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Xiao Y. The "expert patient" approach for non-communicable disease management in low and middle income settings: When the reality confronts the rhetoric. Chronic Dis Transl Med 2015; 1:145-151. [PMID: 29063000 PMCID: PMC5643575 DOI: 10.1016/j.cdtm.2015.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Indexed: 11/05/2022] Open
Abstract
This paper seeks to explore the relevance between the Western “expert patient” rhetoric and the reality of non-communicable diseases (NCDs) control and management in low and middle income settings from the health sociological perspective. It firstly sets up a conceptual framework of the “expert patient” or the patient self-management approach, showing the rhetoric of the initiative in the developed countries. Then by examining the situation of NCDs control and management in low income settings, the paper tries to evaluate the possibilities of implementing the “expert patient” approach in these countries. Kober and Van Damme's study on the relevance of the “expert patient” for an HIV/AIDS program in low income settings is critically studied to show the relevance of the developed countries' rhetoric of the “expert patient” approach for the reality of developing countries. In addition, the MoPoTsyo diabetes peer educator program is analyzed to show the challenges faced by the low income countries in implementing patient self-management programs. Finally, applications of the expert patient approach in China are discussed as well, to remind us of the possible difficulties in introducing it into rural settings.
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Affiliation(s)
- Yue Xiao
- The Center for Health Policy Evaluation and Technology Assessment, The China National Health Development Research Center, Beijing 100910, China
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McPake B, Edoka I, Witter S, Kielmann K, Taegtmeyer M, Dieleman M, Vaughan K, Gama E, Kok M, Datiko D, Otiso L, Ahmed R, Squires N, Suraratdecha C, Cometto G. Cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Bull World Health Organ 2015; 93:631-639A. [PMID: 26478627 PMCID: PMC4581637 DOI: 10.2471/blt.14.144899] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 03/05/2015] [Accepted: 06/19/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. METHODS Incremental cost-effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. Life years gained were estimated based on coverage of reproductive, maternal, neonatal and child health services. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. For Indonesia, coverage of health service interventions was estimated from routine data. We used the Lives Saved Tool to estimate the number of lives saved from changes in reproductive, maternal, neonatal and child health-service coverage. Gross domestic product per capita was used as the reference willingness-to-pay threshold value. FINDINGS The estimated incremental cost per life year gained was 82 international dollars ($)in Kenya, $999 in Ethiopia and $3396 in Indonesia. The results were most sensitive to uncertainty in the estimates of life-years gained. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective. CONCLUSION Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. Community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.
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Affiliation(s)
- Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Ijeoma Edoka
- Institute for International Health & Development, Queen Margaret University, Queen Margaret Drive Musselburgh, Edinburgh EH21 6UU, Scotland
| | - Sophie Witter
- Institute for International Health & Development, Queen Margaret University, Queen Margaret Drive Musselburgh, Edinburgh EH21 6UU, Scotland
| | - Karina Kielmann
- Institute for International Health & Development, Queen Margaret University, Queen Margaret Drive Musselburgh, Edinburgh EH21 6UU, Scotland
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, England
| | | | | | - Elvis Gama
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, England
| | - Maryse Kok
- Royal Tropical Institute, Amsterdam, Netherlands
| | - Daniel Datiko
- REACHOUT, Hidase Hulentenawi Agelglot Yebego Adragot Mahber, Awassa, Ethiopia
| | | | - Rukhsana Ahmed
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, England
| | - Neil Squires
- Public Health England, North of England Region, England
| | - Chutima Suraratdecha
- United States Agency for International Development, Washington, DC, United States of America
| | - Giorgio Cometto
- Global Health Workforce Alliance, World Health Organization, Geneva, Switzerland
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