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Kiendrébéogo JA, Sory O, Kaboré I, Kafando Y, Steege R, George AS, Kumar MB. How does community health feature in Global Financing Facility planning documents to support reproductive, maternal, newborn, child and adolescent health and nutrition (RMNAH-N)? insights from six francophone West African countries. Glob Health Action 2024; 17:2407680. [PMID: 39354843 PMCID: PMC11448318 DOI: 10.1080/16549716.2024.2407680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 09/19/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Community health is key for improving Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). However, how community health supports integrated RMNCAH-N service delivery in francophone West Africa is under-researched. OBJECTIVE We examined how six francophone West African countries (Burkina Faso, Côte d'Ivoire, Guinea, Mali, Niger, and Senegal) support community health through the Global Financing Facility for Women, Children and Adolescents (GFF). METHODS We conducted a content analysis on Investment Cases and Project Appraisal Documents from selected countries, and set out the scope of the analysis and the key search terms. We applied an iterative hybrid inductive-deductive approach to identify themes for data coding and extraction. The extracted data were compared within and across countries and further grouped into meaningful categories. RESULTS In country documents, there is a commitment to community health, with significant attention paid to various cadres of community health workers (CHWs) who undertake a range of preventive, promotive and curative roles across RMNCAH-N spectrum. While CHWs renumeration is mentioned, it varies considerably. Most community health indicators focus on CHWs' deliverables, with few related to governance and civil registration. Challenges in implementing community health include poor leadership and governance and resource shortages resulting in low CHWs performance and service utilization. While some countries invest significantly in training CHWs, structural reforms and broader community engagement are lacking. CONCLUSIONS There is an opportunity to better prioritize and streamline community health interventions, including integrating them into health system planning and budgeting, to fully harness their potential to improve RMNCAH-N.
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Affiliation(s)
- Joël Arthur Kiendrébéogo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
- Research, Expertise and Capacity Building, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Orokia Sory
- Research, Expertise and Capacity Building, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
| | - Issa Kaboré
- Research, Expertise and Capacity Building, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
| | - Yamba Kafando
- Research, Expertise and Capacity Building, Recherche pour la santé et le développement (RESADE), Ouagadougou, Burkina Faso
| | - Rosie Steege
- Department of International Public Health institution, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Asha S George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Meghan Bruce Kumar
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Programme, Nairobi, Kenya
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Chilala SB, Silumbwe A, Zulu JM, Tetui M, Bulawayo M, Chewe M, Hangoma P. Individual, community and health systems factors influencing time to notification of tuberculosis: situating software and hardware bottlenecks in local health systems. BMC Health Serv Res 2024; 24:1241. [PMID: 39415167 DOI: 10.1186/s12913-024-11697-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 10/03/2024] [Indexed: 10/18/2024] Open
Abstract
BACKGROUND Despite several global interventions, tuberculosis (TB) remains a leading cause of death affecting millions of people globally. Many TB patients either have no access to quality care or go undetected by national health systems. Several multilevel factors account for under-detection of persons with TB. This study sought to explore patient-related software, community and health systems software and hardware factors influencing time to notification of TB in Lusaka District, Zambia. METHODS This was an exploratory qualitative case study that adopted a software and hardware lens of conceptualizing health systems. Data were collected from across three sites - urban and peri-urban areas: Chongwe, Kafue, and Lusaka - within Lusaka Province, Zambia. Sixteen key informants - TB corner nurses, community TB treatment supporters, and TB program managers - were interviewed. Six focus groups were held with TB patients. Data were analyzed using thematic analysis. RESULTS The study identified factors influencing timely TB notification, categorized into software and hardware elements. Patient-related software elements, including TB knowledge and awareness, and health-seeking behavior, are crucial for prompt notification among TB patients. In the community health system, software elements like social stigma and undesirable community attitudes towards contact tracing, and hardware elements such as unbalanced schedules, excessive workload and limited capacity of community TB treatment supporters contribute to delayed TB notification. In the formal health system, software elements like negative attitudes of health providers towards TB patients and demotivation of TB staff, and hardware elements such as high diagnostics and transportation costs, outdated diagnostics in primary care facilities, and slow referral mechanisms, can also delay TB notification. CONCLUSION Delays in time to TB notification are influenced by a combination of software (attitudinal and behavioral) and hardware (resource-related) elements across TB patients, community health systems, community TB treatment supporters, health providers, and TB staff. Addressing these factors, particularly social stigma, negative attitudes, and resource constraints, is crucial to improving timely TB detection and treatment.
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Affiliation(s)
- Sandra Beauty Chilala
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Adam Silumbwe
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia.
- Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden.
| | - Joseph Mumba Zulu
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Moses Tetui
- Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Maio Bulawayo
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mwimba Chewe
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
- Chr. Michelson Institute (CMI), P.O. Box 6033, Bergen, N-5892, Norway
- Bergen Centre for Ethics and Priority Setting in Health (BCEPS), University of Bergen, P.O. Box 7804, Bergen, N-5020, Norway
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Zulu JM, Maritim P, Halwiindi H, Chavula MP, Munakampe M, Matenga TFL, Mweemba C, Sinyangwe NN, Habib B, Musukuma M, Silumbwe A, Wang B, Kaonga P, Chewe M, Fisa R, Banda J, Mubanga A, Phiri H. Implementation strategies for decentralized management of multidrug-resistant tuberculosis: insights from community health systems in Zambia. Arch Public Health 2024; 82:157. [PMID: 39277746 PMCID: PMC11401366 DOI: 10.1186/s13690-024-01384-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 08/29/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND Decentralized management approaches for multi-drug-resistant tuberculosis (MDR TB) have shown improved treatment outcomes in patients. However, challenges remain in the delivery of decentralized MDR TB services. Further, implementation strategies for effectively delivering the services in community health systems (CHSs) in low-resource settings have not been fully described, as most strategies are known and effective in high-income settings. Our research aimed to delineate the specific implementation strategies employed in managing MDR TB in Zambia. METHODS Our qualitative case study involved 112 in-depth interviews with a diverse group of participants, including healthcare workers, community health workers, patients, caregivers, and health managers in nine districts. We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) compilation and later grouped them into three CHS lenses: programmatic, relational, and collective action. RESULTS The programmatic lens comprised four implementation strategies: (1) changing infrastructure through refurbishing and expanding health facilities to accommodate management of MDR TB, (2) adapting and tailoring clinical and diagnostic services to the context through implementing tailored strategies, (3) training and educating health providers through ongoing training, and (4) using evaluative and iterative strategies to review program performance, which involved development and organization of quality monitoring systems, as well as audits. Relational lens strategies were (1) providing interactive assistance through offering local technical assistance in clinical expert committees and (2) providing support to clinicians through developing health worker and community health worker outreach teams. Finally, the main collective action lens strategy was engaging consumers; the discrete strategies were increasing demand using community networks and events and involving patients and family members. CONCLUSION This study builds on the ERIC implementation strategies by stressing the need to fully consider interrelations or embeddedness of CHS strategies during implementation processes. For example, to work effectively, the programmatic lens strategies need to be supported by strategies that promote meaningful community engagement (the relational lens) and should be attuned to strategies that promote community mobilization (collective action lens).
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Affiliation(s)
- Joseph Mumba Zulu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Patricia Maritim
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Hikabasa Halwiindi
- Department of Community and Family Medicine, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Malizgani Paul Chavula
- Department of Community and Family Medicine, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia.
- Department of Epidemiology and Global Health, Umeå University, Umeå, 901 87, Sweden.
| | - Margarate Munakampe
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
- Yakini Health Research Institute, Lusaka, Zambia
| | - Tulani Francis L Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Chris Mweemba
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Ntazana N Sinyangwe
- Department of Environmental Health, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Batuli Habib
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Mwiche Musukuma
- Department of Epidemiology and Biostatics, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Adam Silumbwe
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
- Department of Epidemiology and Global Health, Umeå University, Umeå, 901 87, Sweden
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 55 N Lake Ave, 01655, Worcester, MA, USA
| | - Patrick Kaonga
- Department of Epidemiology and Biostatics, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Mwimba Chewe
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Ronald Fisa
- Department of Epidemiology and Biostatics, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia
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South J, Mapplethorpe T, Gledhill R, Marsh W, Stansfield J, Evans S, Mancini M, Outhwaite H. Learning from public health practice: the development of a library of community-centered practice examples. J Public Health (Oxf) 2023; 45:414-422. [PMID: 35774035 PMCID: PMC10273362 DOI: 10.1093/pubmed/fdac065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/28/2022] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Valuable learning derived from public health practice can be captured through practice-based case studies, also known as practice examples. Practice examples of participatory interventions supplement the evidence base by providing information on the complexities of implementation in communities. This paper reports on a Public Health England project to build a bank of community-centered practice examples based on robust processes of collection and curation. METHODS The multidisciplinary project had three phases: (i) development and piloting a process to collect practice examples, (ii) refining review processes and gathering further examples via national and regional teams (iii) maintenance of an accessible collection on the library platform. RESULTS The project resulted in a searchable collection of 55 practice examples illustrating participatory approaches in public health practice. The collection shows diversity in terms of settings, population, focus and type of approach used to work with communities. A secondary outcome was the development of generic guidance and templates for further collections on public health topics. CONCLUSIONS This project illustrates how information on the implementation of community-centered approaches in real-life contexts can be gathered and disseminated through a transferable process. Having collections of practice examples supports knowledge exchange in public health as learning is shared.
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Affiliation(s)
- Jane South
- School of Health, Leeds Beckett University, Leeds LS1 3HE, UK
- Office for Health Improvement and Disparities, Department of Health and Social Care, London SW1H 0EU, UK
| | - Tom Mapplethorpe
- Office for Health Improvement and Disparities, Department of Health and Social Care, London SW1H 0EU, UK
| | - Rachel Gledhill
- UK Health Security Agency Knowledge and Library Services, UK Health Security Agency, London SW1H 0EU, UK
| | - Wendy Marsh
- UK Health Security Agency Knowledge and Library Services, UK Health Security Agency, London SW1H 0EU, UK
| | - Jude Stansfield
- School of Health, Leeds Beckett University, Leeds LS1 3HE, UK
- Office for Health Improvement and Disparities, Department of Health and Social Care, London SW1H 0EU, UK
| | - Sian Evans
- Local Knowledge and Intelligence Service (LKIS) East, Office for Health Improvement and Disparities, Department of Health and Social Care, Cambridge CB21 5XA, UK
| | - Michelle Mancini
- Office for Health Improvement and Disparities, North East and Yorkshire, Department of Health and Social Care, Newcastle NE15 8NY, UK
| | - Helen Outhwaite
- Improvement Directorate, NHS England and NHS Improvement, Leeds LS2 7UE, UK
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Zulu JM, Mwamba T, Rosen A, Matenga TFL, Mulanda J, Kaimba M, Chilembo M, Silondwa M, Kamboyi RL, Simwanza SC, Sichone G, Chavula MP. Community engagement for the Voluntary Medical Male Circumcision (VMMC) program: an analysis of key stakeholder roles to promote a sustainable program in Zambia. Gates Open Res 2023; 6:50. [PMID: 37069966 PMCID: PMC10105033 DOI: 10.12688/gatesopenres.13587.2] [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] [Accepted: 05/18/2023] [Indexed: 05/31/2023] Open
Abstract
Background: Within the Voluntary Medical Male Circumcision (VMMC) programme, community engagement has been central in facilitating the acceptance of VMMC, especially in non-circumcising communities. We used the case of the development of community engagement plans for sustainability of VMMC in Zambia to illustrate diversity of stakeholders, their power, roles, and strategies in community engagement. Methods: Data were collected using document review, in-depth interviews (n=35) and focus group discussions (n=35) with community stakeholders, health workers, health centre committees, counsellors, teachers, community volunteers and parents/caregivers. Data were analysed using thematic analysis. The analysis was guided by the power and interest model. Results: Differences were noted between the rural and urban sites in terms of power/influence and interest rating of community stakeholders who could be involved in the sustainability phase of the VMMC response in Zambia. For example, in the urban setting, neighbourhood health committees (NHCs), health workers, leaders of clubs, community health workers (CHWs), radio, television and social media platforms were ranked highest. From this list, social media and television platforms were not highly ranked in rural areas. Some stakeholders had more sources of power than others. Forms or sources of power included technical expertise, local authority, financial resources, collective action (action through schools, churches, media platforms, other community spaces), and relational power. Key roles and strategies included strengthening and broadening local coordination systems, enhancing community involvement, promoting community-led monitoring and evaluation, through the use of locally recognised communication spaces and channels, facilitating ownership of VMMC, and improving local accountability processes in VMMC activities. Conclusions: By consulting with the most relevant stakeholders, and considering community needs in programme development, the VMMC programme may be able to leverage the community structures and systems to reduce long term demand generation costs for VMMC and increase the acceptability and frequency of male circumcision.
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Affiliation(s)
- Joseph M. Zulu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Trevor Mwamba
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Alyssa Rosen
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Tulani Francis L. Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Joseph Mulanda
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Mutale Kaimba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Masitano Chilembo
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Madaliso Silondwa
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Royd L. Kamboyi
- Ministry of Health, Ministry of Health, Lusaka, Lusaka, 10101, Zambia
| | | | - George Sichone
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Malizgani Paul Chavula
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
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Singh NS, Blanchard AK, Blencowe H, Koon AD, Boerma T, Sharma S, Campbell OMR. Zooming in and out: a holistic framework for research on maternal, late foetal and newborn survival and health. Health Policy Plan 2022; 37:565-574. [PMID: 34888635 PMCID: PMC9113153 DOI: 10.1093/heapol/czab148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 12/03/2022] Open
Abstract
Research is needed to understand why some countries succeed in greater improvements in maternal, late foetal and newborn health (MNH) and reducing mortality than others. Pathways towards these health outcomes operate at many levels, making it difficult to understand which factors contribute most to these health improvements. Conceptual frameworks provide a cognitive means of rendering order to these factors and how they interrelate to positively influence MNH. We developed a conceptual framework by integrating theories and frameworks from different disciplines to encapsulate the range of factors that explain reductions in maternal, late foetal and neonatal mortality and improvements in health. We developed our framework iteratively, combining our interdisciplinary research team's knowledge, experience and review of the literature. We present a framework that includes health policy and system levers (or intentional actions that policy-makers can implement) to improve MNH; service delivery and coverage of interventions across the continuum of care; and epidemiological and behavioural risk factors. The framework also considers the role of context in influencing for whom and where health and non-health efforts have the most impact, to recognize 'the causes of the causes' at play at the individual/household, community, national and transnational levels. Our framework holistically reflects the range of interrelated factors influencing improved MNH and survival. The framework lends itself to studying how different factors work together to influence these outcomes using an array of methods. Such research should inform future efforts to improve MNH and survival in different contexts. By re-orienting research in this way, we hope to equip policy-makers and practitioners alike with the insight necessary to make the world a safer and fairer place for mothers and their babies.
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Affiliation(s)
- Neha S Singh
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Andrea K Blanchard
- Department of Community Health Sciences, University of Manitoba, R070-771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada
| | - Hannah Blencowe
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Ties Boerma
- Department of Community Health Sciences, University of Manitoba, R070-771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada
| | - Sudha Sharma
- CIWEC Hospital and Travel Medical Center, G.P.O. Box 12895, Kapurdhara Marg, Kathmandu 44600, Nepal
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Zulu JM, Mwamba T, Rosen A, Matenga TFL, Mulanda J, Kaimba M, Chilembo M, Silondwa M, Kamboyi RL, Simwanza SC, Sichone G, Chavula MP. Community engagement for the Voluntary Medical Male Circumcision (VMMC) program: an analysis of key stakeholder roles to promote a sustainable program in Zambia. Gates Open Res 2022; 6:50. [PMID: 37069966 PMCID: PMC10105033 DOI: 10.12688/gatesopenres.13587.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Within the Voluntary Medical Male Circumcision (VMMC) programme, community engagement has been central in facilitating the acceptance of VMMC, especially in non-circumcising communities. We used the case of the development of community engagement plans for sustainability of VMMC in Zambia to illustrate diversity of stakeholders, their power, roles, and strategies in community engagement. Methods: Data were collected using document review, in-depth interviews (n=35) and focus group discussions (n=35) with community stakeholders, health workers, health centre committees, counsellors, teachers, community volunteers and parents/caregivers. Data were analysed using thematic analysis. The analysis was guided by the power and interest model. Results: Differences were noted between the rural and urban sites in terms of power/influence and interest rating of community stakeholders who could be involved in the sustainability phase of the VMMC response in Zambia. For example, in the urban setting, neighbourhood health committees (NHCs), health workers, leaders of clubs, community health workers (CHWs), radio, television and social media platforms were ranked highest. From this list, social media and television platforms were not highly ranked in rural areas. Some stakeholders had more sources of power than others. Forms or sources of power included technical expertise, local authority, financial resources, collective action (action through schools, churches, media platforms, other community spaces), and relational power. Key roles and strategies included strengthening and broadening local coordination systems, enhancing community involvement, promoting community-led monitoring and evaluation, through the use of locally recognised communication spaces and channels, facilitating ownership of VMMC, and improving local accountability processes in VMMC activities. Conclusions: By consulting with the most relevant stakeholders, and considering community needs in programme development, the VMMC programme may be able to leverage the community structures and systems to reduce long term demand generation costs for VMMC and increase the acceptability and frequency of male circumcision.
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Affiliation(s)
- Joseph M. Zulu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Trevor Mwamba
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Alyssa Rosen
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Tulani Francis L. Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Joseph Mulanda
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Mutale Kaimba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Masitano Chilembo
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Madaliso Silondwa
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Royd L. Kamboyi
- Ministry of Health, Ministry of Health, Lusaka, Lusaka, 10101, Zambia
| | | | - George Sichone
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Malizgani Paul Chavula
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
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Canuto K, Preston R, Rannard S, Felton-Busch C, Geia L, Yeomans L, Turner N, Thompson Q, Carlisle K, Evans R, Passey M, Larkins S, Redman-MacLaren M, Farmer J, Muscat M, Taylor J. How and why do women's groups (WGs) improve the quality of maternal and child health (MCH) care? A systematic review of the literature. BMJ Open 2022; 12:e055756. [PMID: 35190438 PMCID: PMC8862452 DOI: 10.1136/bmjopen-2021-055756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND This systematic review was undertaken to assist the implementation of the WOmen's action for Mums and Bubs (WOMB) project which explores Aboriginal and Torres Strait Islander community women's group (WG) action to improve maternal and child health (MCH) outcomes. There is now considerable international evidence that WGs improve MCH outcomes, and we were interested in understanding how and why this occurs. The following questions guided the review: (1) What are the characteristics, contextual influences and group processes associated with the MCH outcomes of WGs? (2) What are the theoretical and conceptual approaches to WGs? (3) What are the implications likely to inform Aboriginal and Torres Strait Islander WGs? METHODS We systematically searched electronic databases (MEDLINE (Ovid); CINAHL (Ebsco); Informit health suite, Scopus, Emcare (Ovid) and the Cochrane Library and Informit), online search registers and grey literature using the terms mother, child, group, participatory and community and their variations during all time periods to January 2021. The inclusion criteria were: (1) Population: studies involving community WGs in any country. (2) Intervention: a program/intervention involving any aspect of community WGs planning, acting, learning and reviewing MCH improvements. (3) Outcome: studies with WGs reported a component of: (i) MCH outcomes; or (ii) improvements in the quality of MCH care or (iii) improvements in socioemotional well-being of mothers and/or children. (4) Context: the primary focus of initiatives must be in community-based or primary health care settings. (5) Process: includes some description of the process of WGs or any factors influencing the process. (6) Language: English. (7) Study design: all types of quantitative and qualitative study designs involving primary research and data collection.Data were extracted under 14 headings and a narrative synthesis identified group characteristics and analysed the conceptual approach to community participation, the use of theory and group processes. An Australian typology of community participation, concepts from Aboriginal and Torres Strait Islander group work and an adapted framework of Cohen and Uphoff were used to synthesise results. Risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Tools. RESULTS Thirty-five (35) documents were included with studies conducted in 19 countries. Fifteen WGs used participatory learning and action cycles and the remainder used cultural learning, community development or group health education. Group activities, structure and who facilitated groups was usually identified. Intergroup relationships and decision-making were less often described as were important concepts from an Aboriginal or Torres Strait Islander perspective (the primacy of culture, relationships and respect). All but two documents used an explicit theoretical approach. Using the typology of community participation, WGs were identified as predominantly developmental (22), instrumental (10), empowerment (2) and one was unclear. DISCUSSION A framework to categorise links between contextual factors operating at micro, meso and macro levels, group processes and MCH improvements is required. Currently, despite a wealth of information about WGs, it was difficult to determine the methods through which they achieved their outcomes. This review adds to existing systematic reviews about the functioning of WGs in MCH improvement in that it covers WGs in both high-income and low-income settings, identifies the theory underpinning the WGs and classifies the conceptual approach to participation. It also introduces an Australian Indigenous perspective into analysis of WGs used to improve MCH. PROSPERO REGISTRATION NUMBER CRD42019126533.
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Affiliation(s)
- Karla Canuto
- Aboriginal Health Equity, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Naghir Tribe of the Kulkagul Clan, Torres Strait, Queensland, Australia
| | - Robyn Preston
- School of Health, Medical and Applied Sciences, Central Queensland University, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Sam Rannard
- Library and Information Services, James Cook University, Bebegu Yumba, Townsville, Queensland, Australia
| | - Catrina Felton-Busch
- Murtupuni Centre Rural and Remote Health, James Cook University, Mount Isa, Queensland, Australia
- Yangkaal and Gangaidda, Mount Isa, Queensland, Australia
| | - Lynore Geia
- College of Healthcare Sciences, James Cook University, Bebegu Yumba, Townsville, Queensland, Australia
- Bwgcolman, Palm Island, Queensland, Australia
| | - Lee Yeomans
- Queensland Aboriginal and Islander Health Council, Brisbane, Queensland, Australia
| | - Nalita Turner
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
- Anmatyerre/Jaru, Northern Territory, Northern Territory, Australia
| | - Quitaysha Thompson
- Gurindji Aboriginal Corporation, Kalkaringi, Northern Territory, Australia
- Gurindji woman, Kalkaringi, Northern Territory, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Megan Passey
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Sarah Larkins
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
| | - Michelle Redman-MacLaren
- College of Medicine and Dentistry, James Cook University, Nguma-bada, Cairns, Queensland, Australia
| | - Jane Farmer
- Swinburne Social Innovation Research Institute, Centre for Social Impact, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Melody Muscat
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
- Bijara, Charleville, Queensland, Australia
| | - Judy Taylor
- College of Medicine and Dentistry, James Cook University, Bebegu Yumba,Townsville, Queensland, Australia
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Bellerose M, Gogoi A, Rauf R, Sacks E. Deterministic, not tokenistic: placing women's demands at the centre of health policies and programmes. Sex Reprod Health Matters 2022; 29:2105293. [PMID: 36017910 PMCID: PMC9423829 DOI: 10.1080/26410397.2022.2105293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Meghan Bellerose
- MPH Student, Department of Population and Family Health, Columbia University Mailman School of Public Health, New York City, NY, USA
| | - Aparajita Gogoi
- National Coordinator, White Ribbon Alliance, New Delhi, India
| | - Rafia Rauf
- National Coordinator, White Ribbon Alliance, Islamabad, Pakistan. Correspondence:
| | - Emma Sacks
- Associate Faculty, Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
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10
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Nkole T, Silumbwe A, Munakampe MN, Cordero JP, Milford C, Zulu JM, Steyn PS. Community and health provider perspectives on the quality of family planning and contraceptive services in Kabwe District, Zambia. Sex Reprod Health Matters 2021; 29:1985945. [PMID: 34747352 PMCID: PMC8583990 DOI: 10.1080/26410397.2021.1985945] [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] [Indexed: 11/29/2022] Open
Abstract
Quality family planning and contraceptive (FP/C) services result in positive outcomes such as client satisfaction and sustained use of contraceptives. While most assessments of quality in FP/C services are based on measurable reproductive health outcomes, there is limited consideration of the perspectives and experiences of health providers and community members. This study aimed to address this knowledge gap, by exploring health providers’ and community perspectives on the elements of quality FP/C services in Kabwe district, Zambia. Fourteen focus group discussions and 10 in-depth interviews were conducted in October–December 2016, involving community members, key community stakeholders such as religious and political leaders, health committee members and frontline and managerial healthcare providers. Data were analysed using a thematic approach. According to study participants, quality FP/C services would include provision by skilled personnel with positive attitudes towards clients, availability of preferred methods and affordable products. Additional factors included appropriate infrastructure, especially counselling services spaces and adequate consultation time. Participants stressed the need for reduced waiting time and opportunity for self-expression. The efficiency and effectiveness of service delivery factors, such as information dissemination and community engagement, were also considered important elements of quality FP/C. This study underscores the value of considering both community and health provider perspectives in efforts to improve the quality of FP/C services, with the overall aim of increasing client satisfaction and sustained utilisation. However, service delivery processes must also be addressed in addition to providing for community participation, if quality is to be achieved in FP/C services.
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Affiliation(s)
- Theresa Nkole
- UPTAKE Local Principal Investigator, Gynaecologist, Department of Obstetrics and Gynaecology, Levy Mwanawasa Medical University (LMMU), Lusaka, Zambia
| | - Adam Silumbwe
- UPTAKE Data Associate, Lecturer/Researcher, Department of Health Policy and Management, School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia. Correspondence:
| | - Margarate N Munakampe
- UPTAKE Data Associate, Department of Health Policy and Management, School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia
| | - Joanna Paula Cordero
- UPTAKE Coordinator, Researcher, UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research (SRH), World Health Organization, Geneva, Switzerland
| | - Cecilia Milford
- UPTAKE Qualitative Lead, Researcher, MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Joseph Mumba Zulu
- UPTAKE Data Associate, Department of Health Policy and Management, School of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia
| | - Petrus S Steyn
- UPTAKE Coordinator, Researcher, UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research (SRH), World Health Organization, Geneva, Switzerland
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11
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Kok M, Crigler L, Musoke D, Ballard M, Hodgins S, Perry HB. Community health workers at the dawn of a new era: 10. Programme performance and its assessment. Health Res Policy Syst 2021; 19:108. [PMID: 34641901 PMCID: PMC8506096 DOI: 10.1186/s12961-021-00758-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND While the evidence supporting the effectiveness of community health worker (CHW) programmes is substantial, there is also considerable evidence that many of these programmes have notable weaknesses that need to be addressed in order for them to reach their full potential. Thus, considerations about CHW programme performance and its assessment must be taken into account as the importance of these programmes is becoming more widely appreciated. In this paper, the tenth in our 11-paper series, "Community health workers at the dawn of a new era", we address CHW programme performance and how it is assessed from a systems perspective. METHODS The paper builds on the 2014 CHW Reference Guide, a compendium of case studies of 29 national CHW programmes, the 2018 WHO guideline on health policy and system support to optimize CHW programmes, and scientific studies on CHW programme performance published in the past 5 years. RESULTS The paper provides an overview of existing frameworks that are useful for assessing the performance of CHW programmes, with a specific focus on how individual CHW performance and community-level outcomes can be measured. The paper also reviews approaches that have been taken to assess CHW programme performance, from programme monitoring using the routine health information system to national assessments using quantitative and/or qualitative study designs and assessment checklists. The paper also discusses contextual factors that influence CHW programme performance, and reflects upon gaps and needs for the future with regard to assessment of CHW programme performance. CONCLUSION Assessments of CHW programme performance can have various approaches and foci according to the programme and its context. Given the fact that CHW programmes are complex entities and part of health systems, their assessment ideally needs to be based on data derived from a mix of reliable sources. Assessments should be focused not only on effectiveness (what works) but also on contextual factors and enablers (how, for whom, under what circumstances). Investment in performance assessment is instrumental for continually innovating, upgrading, and improving CHW programmes at scale. Now is the time for new efforts in implementation research for strengthening CHW programming.
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Affiliation(s)
- Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Madeleine Ballard
- Community Health Impact Coalition, New York, NY, USA
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steve Hodgins
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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12
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Perry HB, Chowdhury M, Were M, LeBan K, Crigler L, Lewin S, Musoke D, Kok M, Scott K, Ballard M, Hodgins S. Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All". Health Res Policy Syst 2021; 19:111. [PMID: 34641891 PMCID: PMC8506098 DOI: 10.1186/s12961-021-00755-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [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: 11/24/2022] Open
Abstract
BACKGROUND This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era". METHODS We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. RESULTS CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. CONCLUSION A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.
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Affiliation(s)
- Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | | | | | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway and Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Independent Consultant, Toronto, Canada
| | - Madeleine Ballard
- Community Health Impact Coalition, New York, NY, USA
- Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Steve Hodgins
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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13
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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: 35] [Impact Index Per Article: 11.7] [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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14
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Abstract
BACKGROUND There is now rapidly growing global awareness of the potential of large-scale community health worker (CHW) programmes not only for improving population health but, even more importantly, for accelerating the achievement of universal health coverage and eliminating readily preventable child and maternal deaths. However, these programmes face many challenges that must be overcome in order for them to reach their full potential. FINDINGS This editorial introduces a series of 11 articles that provide an overview highlighting a broad range of issues facing large-scale CHW programmes. The series addresses many of them: planning, coordination and partnerships; governance, financing, roles and tasks, training, supervision, incentives and remuneration; relationships with the health system and communities; and programme performance and its assessment. Above all, CHW programmes need stronger political and financial support, and this can occur only if the potential of these programmes is more broadly recognized. The authors of the papers in this series believe that these challenges can and will be overcome-but not overnight. For this reason, the series bears the title "Community Health Workers at the Dawn of a New Era". The scientific evidence regarding the ability of CHWs to improve population health is incontrovertible, and the favourable experience with these programmes at scale when they are properly designed, implemented, and supported is compelling. CHW programmes were once seen as a second-class solution to a temporary problem, meaning that once the burden of disease from maternal and child conditions and from communicable diseases in low-income countries had been appropriately reduced, there would be no further need for CHWs. That perspective no longer holds. CHW programmes are now seen as an essential component of a high-performing healthcare system even in developed countries. Their use is growing rapidly in the United States, for instance. And CHWs are also now recognized as having a critically important role in the control of noncommunicable diseases as well as in the response to pandemics of today and tomorrow in all low-, middle-, and high-income countries throughout the world. CONCLUSION The promise of CHW programmes is too great not to provide them with the support they need to achieve their full potential. This series helps to point the way for how this support can be provided.
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Affiliation(s)
- Joseph M. Zulu
- Health Promotion and Education Department, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Henry B. Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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15
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Newton-Lewis T, Nanda P. Problematic problem diagnostics: why digital health interventions for community health workers do not always achieve their desired impact. BMJ Glob Health 2021; 6:bmjgh-2021-005942. [PMID: 34312157 PMCID: PMC8728339 DOI: 10.1136/bmjgh-2021-005942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/16/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Priya Nanda
- Measurement, Learning, and Evaluation, Bill & Melinda Gates Foundation India, New Delhi, India
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16
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O'Donovan J, Thompson A, Stiles C, Opintan JA, Kabali K, Willis I, Mutimba ME, Nalweyiso E, Mugabi H, Kateete DP, Ameniko M, Govina G, Weberman R, O'Neil E, Winters N, Mutreja A. Participatory approaches, local stakeholders and cultural relevance facilitate an impactful community-based project in Uganda. Health Promot Int 2021; 35:1353-1368. [PMID: 32068865 PMCID: PMC7785315 DOI: 10.1093/heapro/daz127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Sanitation is a major global challenge that is often addressed at national and international levels, while community opinions and beliefs are neglected. To promote water, sanitation and hygiene (WASH) we organized a cross-cultural knowledge exchange workshop to assess participatory methods for engaging local stakeholders. The workshop included 22 participants from all sectors of society. Practical solutions to sanitation challenges were identified and later shared with a local community. Qualitative and quantitative analyses were used to assess impact and showed participatory methods were highly valued to encourage information sharing among widely varied stakeholders, and that video was a particularly successful approach when engaging with local communities. An 8-month follow-up survey of village members revealed excellent information recall, positive behaviour changes and a desire for future visits. Our evidence suggests that community-based participation helped identify solutions to WASH issues affecting rural communities in resource-poor settings. Engaging in a multicultural knowledge-share was particularly valuable as it enabled participants to recognize they have common challenges and allowed them to share low-cost solutions from their different communities. Our use of video was widely viewed as an ideal means of circulating findings, as it communicated information to people with a wide variety of community roles and to all age groups. Its relevance was increased by adopting a culturally appropriate context by involving local communities in workshop activities. We recommend that research in low- and middle-income countries should be mindful of the environmental context in which WASH is implemented, and encourage acceptance by engaging with communities through the use of varied participatory methods.
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Affiliation(s)
- James O'Donovan
- Department of Education, University of Oxford, Oxford, UK.,Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda
| | - Andrew Thompson
- Department of Medicine, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Christina Stiles
- Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Japheth A Opintan
- Department of Medical Microbiology, University of Ghana, Korle-Bu, Ghana
| | - Ken Kabali
- Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda
| | - Ian Willis
- Department of Medicine, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | | | | | - Henry Mugabi
- Division of Community Services, Omni Med, Mukono, Mukono District, Uganda
| | - David P Kateete
- Makerere University School of Health Sciences, Makerere University, Kampala, Uganda
| | | | - George Govina
- Community Health Water and Sanitation Agency, Accra, Ghana
| | - Rachel Weberman
- University of Illinois College of Medicine-Peoria, Peoria, IL, USA
| | - Edward O'Neil
- Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda.,Department of Emergency Medicine, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| | - Ankur Mutreja
- Department of Medicine, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
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17
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Gadsden T, Jan S, Sujarwoto S, Kusumo BE, Palagyi A. Assessing the feasibility and acceptability of a financial versus behavioural incentive-based intervention for community health workers in rural Indonesia. Pilot Feasibility Stud 2021; 7:132. [PMID: 34162428 PMCID: PMC8220784 DOI: 10.1186/s40814-021-00871-7] [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: 12/18/2020] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia. METHODS CHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation. RESULTS Factors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages. CONCLUSION It was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.
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Affiliation(s)
- Thomas Gadsden
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney School of Public Health, Sydney, Australia
| | - Sujarwoto Sujarwoto
- Department of Public Administration, University of Brawijaya, Malang, Indonesia
| | - Budiarto Eko Kusumo
- Department of Public Administration, University of Brawijaya, Malang, Indonesia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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John A, Nisbett N, Barnett I, Avula R, Menon P. Factors influencing the performance of community health workers: A qualitative study of Anganwadi Workers from Bihar, India. PLoS One 2020; 15:e0242460. [PMID: 33237939 PMCID: PMC7688170 DOI: 10.1371/journal.pone.0242460] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022] Open
Abstract
Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.
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Affiliation(s)
- Aparna John
- Department of International Development, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Nicholas Nisbett
- Health and Nutrition Cluster, Institute of Development Studies, University of Sussex, Brighton, United Kingdom
| | - Inka Barnett
- Health and Nutrition Cluster, Institute of Development Studies, University of Sussex, Brighton, United Kingdom
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
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Schneider H, George A, Mukinda F, Tabana H. District Governance and Improved Maternal, Neonatal and Child Health in South Africa: Pathways of Change. Health Syst Reform 2020; 6:e1669943. [PMID: 32040355 DOI: 10.1080/23288604.2019.1669943] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.
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Affiliation(s)
- Helen Schneider
- School of Public and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa
| | - Asha George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Fidele Mukinda
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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20
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Sarriot E, Shaar AN. Community Ownership in Primary Health Care-Managing the Intangible. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:327-331. [PMID: 33008849 PMCID: PMC7541110 DOI: 10.9745/ghsp-d-20-00427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/15/2022]
Abstract
Although enduringly intangible, community ownership is foundational to primary health care. This intangibility is a reminder of what programs can and should do (create space for dialogue, question their own choices, expand diversity in stakeholder voices making sense of program-induced changes, including through evaluation) and what they cannot do (manage someone else’s ownership).
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Affiliation(s)
| | - Ali Nashat Shaar
- Palestinian Child Institute, An-Najah National University, Nablus, Palestine
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21
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Sacks E, Schleiff M, Were M, Chowdhury AM, Perry HB. Communities, universal health coverage and primary health care. Bull World Health Organ 2020; 98:773-780. [PMID: 33177774 PMCID: PMC7607457 DOI: 10.2471/blt.20.252445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/27/2022] Open
Abstract
Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.
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Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| | - Meike Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| | | | | | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
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Onarheim KH, Moland KM, Molla M, Miljeteig I. 'I wanted to go, but they said wait': Mothers' bargaining power and strategies in care-seeking for ill newborns in Ethiopia. PLoS One 2020; 15:e0233594. [PMID: 32502223 PMCID: PMC7274445 DOI: 10.1371/journal.pone.0233594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 05/09/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction To prevent the 2.6 million newborn deaths occurring worldwide every year, health system improvements and changes in care-taker behaviour are necessary. Mothers are commonly assumed to be of particular importance in care-seeking for ill babies; however, few studies have investigated their participation in these processes. This study explores mothers’ roles in decision making and strategies in care-seeking for newborns falling ill in Ethiopia. Methods A qualitative study was conducted in Butajira, Ethiopia. Data were collected during the autumn of 2015 and comprised 41 interviews and seven focus group discussions. Participants included primary care-takers who had experienced recent newborn illness or death, health care workers and community members. Data were analysed using thematic analysis. Results Choices about whether, where and how to seek care for ill newborns were made through cooperation and negotiation among household members. Mothers were considered the ones that initially identified or recognised illness, but their actual opportunities to seek care were bounded by structural and cultural constraints. Mothers’ limited bargaining power, contained by financial resources and gendered decision making, shaped their roles in care-seeking. We identified three strategies mothers took on in decision making for newborn illness: (a) acceptance and adaptation (to the lack of options), (b) negotiation and avoidance of advice from others, and (c) active care-seeking and opposition against the husband’s or community’s advice. Conclusion While the literature on newborn health and parenting emphasizes the key role of mothers in care-seeking, their actual opportunities to seek care are shaped by factors commonly beyond their control. Efforts to promote care-seeking for ill children should recognise that mothers’ capabilities to make decisions are embedded in gendered social processes and financial power structures. Thus, policies should not only target individual mothers, but the wider decision making group, including the head of households and extended family.
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Affiliation(s)
- Kristine Husøy Onarheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Institute for Global Health, University College London, London, United Kingdom
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
- * E-mail:
| | - Karen Marie Moland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
| | - Mitike Molla
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ingrid Miljeteig
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Research and Development, Helse Bergen Health Trust, Bergen, Norway
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23
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Structural determinants of gender inequality: why they matter for adolescent girls’ sexual and reproductive health. BMJ 2020. [PMCID: PMC7461912 DOI: 10.1136/bmj.l6985] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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John A, Newton-Lewis T, Srinivasan S. Means, Motives and Opportunity: determinants of community health worker performance. BMJ Glob Health 2019; 4:e001790. [PMID: 31749996 PMCID: PMC6830049 DOI: 10.1136/bmjgh-2019-001790] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/24/2019] [Accepted: 10/05/2019] [Indexed: 11/13/2022] Open
Abstract
The performance of community health workers (CHWs) typically depends on the interaction between their motivation (their intent to achieve personal and organisational goals) and the constraints that they face in doing so. These constraints can be both at the individual level, for example, whether the worker has the skills and knowledge required to deliver on their job role, and the organisational level, for example, whether the worker is provided with the resources required to perform. Designing interventions to improve the performance of CHWs requires identifying the constraints to performance in a particular context. Existing frameworks on CHW performance tend to be derived empirically, identifying a broad range of intervention design and contextual factors that have been shown to influence CHW performance. These may not always be able to guide policy makers to identify the precise cause of a specific performance problem in a particular context and develop an appropriate policy response. This article presents a framework to help practitioners and researchers diagnose the constraints to performance of CHWs and guide programmatic and policy responses. The Means, Motives and Opportunity (MMO) framework has been adapted from the SaniFOAM framework used to identify the determinants of sanitation behaviours. It is based on three interdependent and interacting domains: means (whether an individual is capable of performing), motives (whether an individual wants to perform) and opportunity (whether the individual has the chance to perform). A wide range of data sources are expected to be used when applying the MMO framework, especially qualitative research that captures the perspectives and lived realities of CHWs and their communities. In this article, we demonstrate how the MMO framework can be applied to identify the constraints to CHW performance using the case study of Anganwadi Workers (village nutrition workers) in Bihar, India.
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Affiliation(s)
- Aparna John
- Institute of Development Studies, University of Sussex, Brighton, UK
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McEvoy R, Tierney E, MacFarlane A. 'Participation is integral': understanding the levers and barriers to the implementation of community participation in primary healthcare: a qualitative study using normalisation process theory. BMC Health Serv Res 2019; 19:515. [PMID: 31337391 PMCID: PMC6651937 DOI: 10.1186/s12913-019-4331-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/08/2019] [Indexed: 02/03/2023] Open
Abstract
Background Many international health policies recognise the World Health Organization’s (2008) vision that communities should be involved in shaping primary healthcare services. However, researchers continue to debate definitions, models, and operational challenges to community participation. Furthermore, there has been no use of implementation theory to study how community participation is introduced and embedded in primary healthcare in order to generate insights and transferrable lessons for making this so. Using Normalisation Process Theory (NPT) as a conceptual framework, this qualitative study was designed to explore the levers and barriers to the implementation of community participation in primary healthcare as a routine way of working. Methods We conducted two qualitative studies based on a national Initiative designed to support community participation in primary care in Ireland. We had a combined multi-stakeholder purposeful sample (n = 72), utilising documentary evidence (study 1), semi-structured interviews (studies 1 and 2) and focus groups (study 2). Data generation and analysis were informed by Participatory Learning and Action (PLA) Research Methodology and NPT. Results For many stakeholders, community participation in primary healthcare was a new way of working. Stakeholders did not always have a clear, shared understanding of the aims, objectives and benefits of this way of working and getting involved in a specific project sometimes provided this clarity. Drivers/champions, and strong working partnerships, were considered integral to its initiation and implementation. Participants emphasised the benefits of funding, organisational support, training and networking to enact relevant activities. Health-promoting activities and healthcare consultation/information events were generally successful, but community representation on interdisciplinary Primary Care Teams proved more challenging. Overall, participants were broadly positive about the impacts of community participation, but were concerned about the scope to sustain the work without the ‘protected’ space and resources that the national Initiative afforded. Conclusions Despite the success of specific activities undertaken as part of a community process in Irish primary healthcare, the likelihood of this becoming a routine way of working in Ireland is low. Analysing the learning from this process using NPT provides theoretically informed recommendations that are transferrable to other settings and can be used to prospectively design and formatively evaluate community participation processes. Electronic supplementary material The online version of this article (10.1186/s12913-019-4331-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel McEvoy
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
| | - Edel Tierney
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Anne MacFarlane
- Professor of Primary Healthcare Research, Graduate Entry Medical School, And Health Research Institute, University of Limerick, Limerick, Ireland
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26
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Van Lith T, Beerse M. Examination of Contemporary and Promising Research Strategies in Art Therapy. ART THERAPY 2019. [DOI: 10.1080/07421656.2019.1645499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sacks E, Morrow M, Story WT, Shelley KD, Shanklin D, Rahimtoola M, Rosales A, Ibe O, Sarriot E. Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all. BMJ Glob Health 2019; 3:e001384. [PMID: 31297243 PMCID: PMC6591791 DOI: 10.1136/bmjgh-2018-001384] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 11/03/2022] Open
Abstract
Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.
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Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Melanie Morrow
- Community Health Team, USAID Maternal and Child Survival Program/ICF, Washington, District of Columbia, USA
| | - William T Story
- Department of Community and Behavioral Health, University of Iowa, Iowa City, Iowa, USA
| | | | - D Shanklin
- CORE Inc, Washington, District of Columbia, USA
| | - Minal Rahimtoola
- Independent Health Systems Consultant, Boston, Massachusetts, USA
| | | | - Ochiawunma Ibe
- Community Health Team, USAID Maternal and Child Survival Program/ICF, Washington, District of Columbia, USA
| | - Eric Sarriot
- Global Health, Save the Children Federation Inc, Washington, District of Columbia, USA
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Agarwal S, Kirk K, Sripad P, Bellows B, Abuya T, Warren C. Setting the global research agenda for community health systems: literature and consultative review. HUMAN RESOURCES FOR HEALTH 2019; 17:22. [PMID: 30898136 PMCID: PMC6429801 DOI: 10.1186/s12960-019-0362-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/12/2019] [Indexed: 05/04/2023]
Abstract
BACKGROUND Globally, there is renewed interest in and momentum for strengthening community health systems, as also emphasized by the recent Astana Declaration. Recent reviews have identified factors critical to successful community health worker (CHW) programs but pointed to significant evidence gaps. This review aims to propose a global research agenda to strengthen CHW programs. METHODS AND RESULTS We conducted a search for extant systematic reviews on any intermediate factors affecting the effectiveness of CHW programs in February 2018. A total of 30 articles published after year 2000 were included. Data on research gaps were abstracted and summarized under headings based on predominant themes identified in the literature. Following this data gathering phase, two technical advisory groups comprised of experts in the field of community health-including policymakers, implementors, researchers, advocates and donors-were convened to discuss, validate, and prioritize the research gaps identified. Research gap areas that were identified in the literature and validated through expert consultation include selection and training of CHWs, community embeddedness, institutionalization of CHW programs (referrals, supervision, and supply chain), CHW needs including incentives and remuneration, governance and sustainability of CHW programs, performance and quality of care, and cost-effectiveness of CHW programs. Priority research questions included queries on effective policy, financing, governance, supervision and monitoring systems for CHWs and community health systems, implementation questions around the role of digital technologies, CHW preferences, and drivers of CHW motivation and retention over time. CONCLUSIONS As international interest and investment in CHW programs and community health systems continue to grow, it becomes critical not only to analyze the evidence that exists, but also to clearly define research questions and collect additional evidence to ensure that CHW programs are effective, efficient, equity promoting, and evidence based. Generally, the literature places a strong emphasis on the need for higher quality, more robust research.
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Affiliation(s)
- Smisha Agarwal
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington DC, 20009 United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205 United States of America
| | - Karen Kirk
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington DC, 20009 United States of America
| | - Pooja Sripad
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington DC, 20009 United States of America
| | - Ben Bellows
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington DC, 20009 United States of America
| | - Timothy Abuya
- Population Council, Avenue 5, 3rd Floor, Rose Avenue, Nairobi, Kenya
| | - Charlotte Warren
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington DC, 20009 United States of America
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Gram L, Daruwalla N, Osrin D. Understanding participation dilemmas in community mobilisation: can collective action theory help? J Epidemiol Community Health 2018; 73:90-96. [PMID: 30377247 PMCID: PMC6839791 DOI: 10.1136/jech-2018-211045] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 08/28/2018] [Accepted: 10/12/2018] [Indexed: 11/24/2022]
Abstract
Community mobilisation interventions have been used to promote health in many low-income and middle-income settings. They frequently involve collective action to address shared determinants of ill-health, which often requires high levels of participation to be effective. However, the non-excludable nature of benefits produced often generates participation dilemmas: community members have an individual interest in abstaining from collective action and free riding on others’ contributions, but no benefit is produced if nobody participates. For example, marches, rallies or other awareness-raising activities to change entrenched social norms affect the social environment shared by community members whether they participate or not. This creates a temptation to let other community members invest time and effort. Collective action theory provides a rich, principled framework for analysing such participation dilemmas. Over the past 50 years, political scientists, economists, sociologists and psychologists have proposed a plethora of incentive mechanisms to solve participation dilemmas: selective incentives, intrinsic benefits, social incentives, outsize stakes, intermediate goals, interdependency and critical mass theory. We discuss how such incentive mechanisms might be used by global health researchers to produce new questions about how community mobilisation works and conclude with theoretical predictions to be explored in future quantitative or qualitative research.
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Affiliation(s)
- Lu Gram
- Institute for Global Health, University College London, London, UK
| | - Nayreen Daruwalla
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, India
| | - David Osrin
- Institute for Global Health, University College London, London, UK
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