Increasing community health worker productivity and effectiveness: a review of the influence of the work environment

Protocol to develop strategies to improve the effectiveness and efficiency of Village Health Workers in service delivery in a selected district of Zimbabwe

Village Health Workers (VHWs) in Zimbabwe complement the healthcare staff in primary health care delivery. In 2015 the Ministry of Health streamlined services offered by the VHWs with the VHW Strengthening Plan to improve the effectiveness of the program. However, these continue to offer services not addressing the current and emerging health problems. This three-phased study seeks to develop strategies to improve the effectiveness and efficiency of VHWs in service delivery. Systematic literature review shall be used to develop a conceptual framework to guide the development of VHWs service delivery strategies. Exploratory sequential mixed methods design shall explore VHWs roles in primary health care. A survey in the first stage shall collect qualitative data from 45 purposely selected healthcare workers and VHWs using interviews and then thematically analyzed with MAXQDA. The variables generated will have a cross-sectional survey used to collect quantitative data from 134 VHWs and analyzed on SPSS. The SWOT and basic logic models shall be used to develop strategies validated by the Delphi Technique and Key Stakeholders. Informed consent will be maintained in the study with findings published in journals and presentation symposiums. This protocol was approved by the University of Venda Research Ethics Committee (Registration FHS/23/pH/11/0709).

Health workers' perspectives on the quality of maternal and newborn health care around the time of childbirth: Results of the Improving MAternal Newborn carE in the EURO Region (IMAgiNE EURO) project in 12 countries of the World Health Organization European Region

Background

Health workers' (HWs') perspectives on the quality of maternal and newborn care (QMNC) are not routinely collected. In this cross-sectional study, we aimed to document HWs' perspectives on QMNC around childbirth in 12 World Health Organization (WHO) European countries.

Methods

HWs involved in maternal/neonatal care for at least one year between March 2020 and March 2023 answered an online validated WHO standards-based questionnaire collecting 40 quality measures for improving QMNC. A QMNC index (score 0-400) was calculated as a synthetic measure.

Results

Data from 4143 respondents were analysed. For 39 out of 40 quality measures, at least 20% of HWs reported a 'need for improvement', with large variations across countries. Effective training on healthy women/newborns management (n = 2748, 66.3%), availability of informed consent job aids (n = 2770, 66.9%), and effective training on women/newborns rights (n = 2714, 65.5%) presented the highest proportion of HWs stating 'need for improvement'. Overall, 64.8% (n = 2684) of respondents declared that HWs' numbers were insufficient for appropriate care (66.3% in Portugal and 86.6% in Poland), and 22.4% described staff censorship (16.3% in Germany and 56.7% in Poland). The reported QMNC index was low in all countries (Poland median (MD) = 210.60, interquartile range (IQR) = 155.71, 273.57; Norway MD = 277.86; IQR = 244.32, 308.30). The 'experience of care' domain presented in eight countries had significantly lower scores than the other domains (P < 0.001). Over time, there was a significant monthly linear decrease in the QMNC index (P < 0.001), lacking correlation with the coronavirus disease 2019 (COVID-19) pandemic trends (P > 0.05). Multivariate analyses confirmed large QMNC variation by country. HWs with <10 years of experience, HWs from public facilities, and midwives rated QMNC with significantly lower scores (P < 0.001).

Conclusions

HWs from 12 European countries reported significant gaps in QMNC, lacking association with COVID-19 pandemic trends. Routine monitoring of QMNC and tailored actions are needed to improve health services for the benefit of both users and providers.

Registration

ClinicalTrials.gov NCT04847336.

Expanded roles of community health workers to sustain malaria services in the Asia-Pacific: A landscaping survey

Malaria Community Health Workers (CHWs) in the Greater Mekong Subregion (GMS) are an important component of malaria elimination efforts. As malaria declines with intensified efforts to eliminate by 2030, expanding their roles beyond malaria could help to sustain funding and provision of malaria services at the community level. Evidence of how programmes have implemented and managed CHWs performing both malaria and non-malaria roles across the Asia-Pacific region can provide insight into the viability of this strategy. A short survey was distributed to national malaria programmes and implementing organizations in the Asia-Pacific region in 2021-2022. The survey identified CHW programmes in the region, and collected information on malaria and non-malarial services provided by CHWs, characteristics of each identified programme, and the impact of COVID-19 on these programmes. 35 survey responses identified 28 programmes in 14 countries. The most frequently reported services provided by malaria CHWs were health promotion and education for malaria (13/14 countries) and other diseases (11/14); and COVID-19 related activities (10/14). Most programmes were financed wholly through donor funding (18/28 programmes), or donor plus government funding (6/28). Of 21 programmes which performed programme evaluation, only 2 evaluated their impacts on diseases beyond malaria. Declining donor funding, and COVID-19 related travel and activity restrictions were identified as implementation challenges. CHWs across the Asia Pacific provide a range of health services with malaria and are resilient under changing public health landscapes such as the COVID-19 pandemic. Further investigation into the impact of additional roles on malaria CHW performance and targeted health outcomes is needed to verify the benefits and feasibility of role expansion. As the GMS approaches elimination, and funding declines, verifying the cost effectiveness of malaria CHW programmes will be vital to persuade donors and countries to invest in malaria CHWs to sustain malaria services, and strengthen community-based health care.

Integrating humanities in healthcare: a mixed-methods study for development and testing of a humanities curriculum for front-line health workers in Karachi, Pakistan

Lady health workers (LHWs) provide lifesaving maternal and child health services to >60% of Pakistan's population but are poorly compensated and overburdened. Moreover, LHWs' training does not incorporate efforts to nurture attributes necessary for equitable and holistic healthcare delivery. We developed an interdisciplinary humanities curriculum, deriving its strengths from local art and literature, to enhance character virtues such as empathy and connection, interpersonal communication skills, compassion and purpose among LHWs. We tested the curriculum's feasibility and impact to enhance character strengths among LHWs.We conducted a multiphase mixed-methods pilot study in two towns of Karachi, Pakistan. We delivered the humanities curriculum to 48 LHWs via 12 weekly sessions, from 15 June to 2 September 2021. We developed a multiconstruct character strength survey that was administered preintervention and postintervention to assess the impact of the training. In-depth interviews were conducted with a subset of randomly selected participating LHWs.Of 48 participants, 47 (98%) completed the training, and 34 (71%) attended all 12 sessions. Scores for all outcomes increased between baseline and endline, with highest increase (10.0 points, 95% CI 2.91 to 17.02; p=0.006) observed for empathy/connection. LHWs provided positive feedback on the training and its impact in terms of improving their confidence, empathy/connection and ability to communicate with clients. Participants also rated the sessions highly in terms of the content's usefulness (mean: 9.7/10; SD: 0.16), the success of the sessions (mean: 9.7/10; SD: 0.17) and overall satisfaction (mean: 8.2/10; SD: 3.3).A humanities-based training for front-line health workers is a feasible intervention with demonstrated impact of nurturing key character strengths, notably empathy/connection and interpersonal communication. Evidence from this study highlights the value of a humanities-based training, grounded in local literature and cultural values, that can ultimately translate to improved well-being of LHWs thus contributing to better health outcomes among the populations they serve.

The effect of epilepsy self-management on productivity at work

BACKGROUND

Epilepsy is a significant public health concern and the most common neurological disorder. Lack of understanding of the disease may magnify the challenges faced by employees with epilepsy, including effective management of symptoms, and full participation in workplace and work productivity.

AIM

Study aimed to evaluate epilepsy self-management skills of working individuals with epilepsy and to determine the impact of it on productivity at work.

METHODS

The study adopted a cross-sectional design and involved 111 individuals with epilepsy. Data collection was carried out using a socio-demographic characteristics form, the "Epilepsy Self-Management Scale" and the "Endikot Work Productivity Scale."

RESULTS

The average age was 35.76 ± 3.39 in the study. The majority of the participants (57.7 %) were women. Additionally, 33.3 % were private sector employee, and 39.6 % held a bachelor's degree. The mean score of the Epilepsy Self Management Scale was 3.91 ± 0.15, the total score of Endikot Work Productivity Scale was 39.84 ± 6.33. A negative significant correlation was observed between epilepsy self management and work productivity. Moreover, women (3.94 ± 0.17) and healthcare workers (3.97 ± 0.06) had higher scores of epilepsy self management. While men (40.43 ± 0.15) demonstrated higher productivity scores, public servants (35.61 ± 0.34) had lower scores compared to others (p < 0.05).

CONCLUSIONS

The findings of this study suggest that improved self-management of epilepsy among working individuals leads to increased work productivity. The epilepsy-management skills of women and healthcare workers was higher. Furthermore, men exhibited lower productivity levels, while woman and public servants displayed higher.

Exploring the Relationship between Surface Acting, Job Stress, and Emotional Exhaustion in Health Professionals: The Moderating Role of LMX

Rapid organizational changes due to technological advancements, high-efficiency expectations, and uncertainties, particularly in healthcare, have led to a global stress epidemic among em-ployees. This has been exacerbated by the COVID-19 pandemic and evolving workplace practices. Surface acting, or the suppression and faking of emotions, significantly contributes to this stress and burnout, impacting not only individual healthcare professionals but also healthcare systems' overall effectiveness and sustainability. Providing adequate resources in high-demand work environments is, thus, essential to mitigate these negative experiences. Leader-member exchange (LMX) can play a pivotal role in understanding and addressing the needs and expectations of healthcare professionals. Drawing on Conservation of Resources (COR), Job Demands-Resources (JD-R), Social Exchange theories, and Grandey's Emotional Regulation Model, this study analyzed data from a convenience sample of 350 healthcare professionals. The results reveal that surface acting intensifies healthcare professionals' experiences of job stress and emotional exhaustion. Notably, the study empirically demonstrated that high levels of LMX in healthcare professionals' relationships with their leaders can mitigate the impact of surface acting on job stress and emotional exhaustion. These findings offer valuable insights for managers and policymakers, highlighting the importance of LMX in maintaining sustainable management practices in complex and stressful healthcare organizations.

Implementing supportive supervision in acute humanitarian emergencies: Lessons learned from Afghanistan and Ukraine

Mental Health and Psychosocial Support (MHPSS) practitioners working in humanitarian contexts are at significant risk of mental health conditions, ultimately hindering the quality and sustainability of their work. Supportive supervision has shown to be effective in improving the wellbeing of MHPSS staff and volunteers and enhancing the effectiveness of MHPSS service delivery. Despite these proven benefits, there is a lack of standardised guidelines to inform supportive supervision within humanitarian contexts. To address this gap, the Trinity Centre for Global Health and the International Federation of the Red Cross Red Crescent Societies' Reference Centre for Psychocosial Support co-developed the 'Integrated Model for Supervision' (IMS) Handbook and supporting tools and led IMS trainings with four humanitarian organisations in Ukraine, Afghanistan, Jordan, and Nigeria from June-August 2021. The subsequent acute humanitarian emergencies that occurred in Afghanistan and Ukraine provided the opportunity to (i) examine the implementation of the IMS in the acute stages of two humanitarian crises and (ii) identify the challenges and lessons learned from this process. This study employed a case study design using semi-structured qualitative interviews with five MHPSS personnel (female: 4; male: 1) who had received training in the IMS and were directly involved in the implementation of supportive supervision using IMS guidelines in either Ukraine or Afghanistan. Results showed that participants identified the key steps needed for the implementation of supportive supervision and reported two significant barriers to implementation including the stress of a humanitarian crisis leading to competing responsibilities and priorities, staff shortages and time constraints as well as the challenge of creating a new supervision structure when none had existed previously. Overall, participants felt that the IMS resulted in improved knowledge, confidence, perceived support, team cohesion, staff wellbeing and was a helpful blueprint to guide the implementation of supportive supervision in humanitarian contexts.

An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change

BACKGROUND

Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).

METHODS

We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.

RESULTS

Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.

CONCLUSIONS

Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.

Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic

BACKGROUND

In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia.

METHODS

In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes.

RESULTS

We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies.

CONCLUSION

The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.

Barriers and Enablers of Postnatal Care by Accredited Social Health Activist (ASHA) Workers: A Community-Based Qualitative Study From Tribal Gujarat

Background The care provided to the mother and child from delivery to six weeks after is defined as postnatal care. The postnatal period is both a happy and critical phase for the mother and the newborn. However, the provision of high-quality care services is often ignored during this time. The objective of this study was to assess postnatal care services quality by Accredited Social Health Activist (ASHA) workers and associated factors such as newborn care in rural tribal areas of Gujarat, India. Methodology An ethnographic approach was adopted. Four primary health centers (PHCs) were selected purposively from Sankheda Block, Chhotaudepur, a tribal district in the eastern part of Gujarat. Information on obstacles and facilitators of postnatal care services was collected using in-depth interviews (IDIs) with a purposive sample of 22 ASHAs working in selected PHCs. Qualitative data were analyzed using thematic analysis. Results The median age of the ASHA workers was 39 years and ranged from 30 to 51 years (N = 22). Most ASHAs encountered logistical challenges when offering postnatal care services (e.g., they struggled to care for the mother and her babies because they were missing essential equipment, such as a thermometer and a salter-type baby weighing machine, or they had broken equipment). The two main issues facing ASHAs were incentives and timely payments. There were concerns about their safety and physical security during fieldwork. The majority of ASHA workers had good experiences during postnatal home visits, and they received support from other healthcare workers. There were many misconceptions and false assumptions in the community regarding breastfeeding, prelacteal feeding, family planning, and contraception methods. ASHAs wanted to become long-term government employees and believed they were entitled to sufficient training, assistance, recognition, and remuneration for the duties they performed. Conclusions Postnatal mothers receive considerably less attention than antenatal mothers because it mostly depends on ASHA workers and field staff. ASHA workers are doing their best regarding postnatal care. This study revealed some issues ASHAs face, including logistic issues, transportation issues, regular and timely payment issues, and local-level acceptance issues.

Effects of instructional video and community radio broadcasting interventions to improve knowledge and behavior of antibiotic use in the COVID-19 era

BACKGROUND

Antibiotic overuse is a serious health issue. It has been demonstrated that improper antibiotic use is linked to a lack of knowledge in the public. To encourage judicious antibiotic use in the COVID-19 ERA, it is critical to provide accessible and secure therapies.

OBJECTIVES

This study aimed to assess the effects of instructional video and community radio broadcasting interventions on knowledge and behavior of antibiotic use.

METHODS

Adults over the age of 20 were enrolled in a quasi-experimental study. A total of 369 representatives were divided into two groups: 185 participants in the control group and 184 participants in the intervention group. Data were collected twice, before and after the educational program by community health workers. Both descriptive and inferential statistics were used to analyze the data.

RESULTS

The participants' average age was 56.4 ± 0.6 years. Most of the respondents were female (264, 71.5%) and had only received an elementary education (186, 50.4%). A mean difference score was produced for the control and intervention groups. Both groups experienced a statistically significant gain in mean difference score of knowledge following the educational program (3.42 ± 4.18, [95% CI 2.81-4.02] vs 5.42 ± 4.97, [95% CI 4.69-6.14]) (P < 0.001). A mean difference score was produced with behavior (1.78 ± 3.45, [95% CI 1.28-2.28] vs 2.77 ± 3.06, [95% CI 2.28-3.27]) (P < 0.001). A mean difference in knowledge score between the groups was greater, with the intervention group scoring higher; all significant variables were controlled by multivariable regression analysis (1.31 [95% CI 0.53-2.09]) (P = 0.001). Similarly, a mean difference behavior score (1.34 [95% CI 0.82-1.86]) (P < 0.001).

CONCLUSION

The integration of an educational poster, instructional video, and community radio broadcasting interventions about antibiotic use through CHWs in local communities is beneficial. This program should be implemented at the national level to promote rational drug use. Future studies should investigate how the educational program affects antibiotic use rates in the long term.

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

BACKGROUND

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

OBJECTIVES

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

METHODS

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

RESULTS

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

CONCLUSION

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

TRIAL REGISTRATION

NCT05551728 in Clinical Trial Registry (https://clinicaltrials.gov).

Retention of Community Health Workers in the Public Health Workforce: Public Health Workforce Interests and Needs Survey, 2017 and 2021

Objectives. To investigate the organizational factors contributing to the intent of community health workers (CHWs) to quit their jobs in local and state health departments in the United States. Methods. We used the 2017 (n = 844) and 2021 (n = 1014) Public Health Workforce Interests and Needs Survey data sets to predict CHWs' intent to leave with Stata 17 balanced repeated replication survey estimations. Results. CHWs dissatisfied with organizational support, pay, or job security had high probabilities of reporting an intent to leave (50%, P < .01; 39%, P < .01; and 42%, P < .01, respectively) relative to satisfied or neutral workers (24%, P < .01; 21%, P < .01; and 26%, P < .01, respectively). Conclusions. Improving organizational support, pay satisfaction, and job security satisfaction in public health agencies can significantly improve CHW retention, potentially lowering overall organizational costs, enhancing organizational morale, and promoting community health. Public Health Implications. Our findings shed light on actionable ways to improve CHW retention, including assessing training needs; prioritizing diversity, equity, and inclusion; and improving communication between management and workers. (Am J Public Health. 2024;114(1):44-47. https://doi.org/10.2105/AJPH.2023.307462).

Effectiveness of a government-led, multiarm intervention on early childhood development and caregiver mental health: a study protocol for a factorial cluster-randomised trial in rural China

INTRODUCTION

The high incidences of both the developmental delay among young children and the mental health problems of their caregivers are major threats to public health in low-income and middle-income countries. Parental training interventions during early childhood have been shown to benefit early development, yet evidence on strategies to promote caregiver mental health remains limited. In addition, evidence on the optimal design of scalable interventions that integrate early child development and maternal mental health components is scarce.

METHODS AND ANALYSIS

We design a single-blind, factorial, cluster-randomised controlled, superiority trial that will be delivered and supervised by local agents of the All China Women's Federation (ACWF), the nationwide, government-sponsored social protection organisation that aims to safeguard the rights and interests of women and children. We randomise 125 villages in rural China into four arms: (1) a parenting stimulation arm; (2) a caregiver mental health arm; (3) a combined parenting stimulation and caregiver mental health arm and (4) a pure control arm. Caregivers and their children (aged 6-24 months at the time of baseline data collection) are selected and invited to participate in the 12-month-long study. The parenting stimulation intervention consists of weekly, one-on-one training sessions that follow a loose adaptation of the Reach Up and Learn curriculum. The caregiver mental health intervention is comprised of fortnightly group activities based on an adaptation of the Thinking Healthy curriculum from the WHO. Primary outcomes include measures of child development and caregiver mental health. Secondary outcomes include a comprehensive set of physical, psychological and behavioural outcomes. This protocol describes the design and evaluation plan for this programme.

ETHICS AND DISSEMINATION

This study received approval from the Institutional Review Board of Stanford University (IRB Protocol #63680) and the Institutional Review Board of the Southwestern University of Finance and Economics in Chengdu, Sichuan, China. Informed oral consent will be obtained from all caregivers for their own and their child's participation in the study. The full protocol will be publicly available in an open-access format. The study findings will be published in economics, medical and public health journals, as well as Chinese or English policy briefs.

TRIAL REGISTRATION NUMBER

AEA RCT Registry (AEARCTR-0010078) and ISRCTN registry (ISRCTN84864201).

Female community health volunteers' experience in navigating social context while providing basic diabetes services in western Nepal: Social capital and beyond from systems thinking

The global burden of non-communicable diseases (NCDs) has led to an increased mobilization of community health workers (CHWs) in the prevention and management of NCDs, particularly in resource-poor settings. However, little is known about the experiences of CHWs as they navigate the complex social context while proving home-based NCD management. This study aims to explore the experiences of female community health volunteers (FCHVs) in a community-based pilot project in western Nepal, specially regarding the social challenges they face while delivering basic type 2 diabetes (T2D) services. Using a qualitative phenomenological approach, the study conducted two focus group discussions and nine in-depth interviews with a total of 14 and 9 FCHVs, respectively. Social Capital theory was employed to understand the sociological aspects. The findings shed light on the challenges encountered by FCHVs in expanding their social networks, building trust, and fostering reciprocity among T2D intervention recepients. Notably, social trust was a significant challenge, compounded by power dynamics related to gender and socioeconomic status. FCHVs managed to overcome these challenges through their perseverance, self-motivation, and leaveraging their strong bonding and linking social capital. The recognition they received from the community played a crucial role in sustaining their motivation. The study highlights the importance of FCHVs' strong social capital, supported by available resources and personal motivation, in overcoming social obstacles. It is imperative for community health interventions to anticipate challenges across various elements of social capital to ensure the long-term retention and motivation of CHWs. Establishing appropriate support systems that address personal motivating factors and the strengthen social capital is essential.

A situational analysis of human resource and non-communicable diseases management for community health workers in Chengdu, China: a cross-sectional study

BACKGROUND

Non-communicable diseases (NCDs) pose a major challenge to health economic cost and residents' health status. Community health workers (CHWs) are the gatekeeper of primary health care.

OBJECTIVE

This study aimed to conduct a situational analysis of current human resource and requirements of NCDs-related training among CHWs in Chengdu with regard to address to understand the suggestions for improvement of challenges and barriers.

METHODS

A descriptive online cross-sectional survey was conducted among CHWs (doctors and nurses) from 23 districts and counties in Chengdu. Sociodemographic and NCDs-related variables were collected. Univariate analysis and multiple response analysis were used to describe the characteristics of these variables.

RESULTS

711 doctors and 637 nurses completely responded. There were significant differences among gender, age, educational levels, professional title, working year, type of institution, urban circle and registration in general practice between doctors and nurses (P < 0.001). 60.6% of doctors were female, compared to 98.0% for nurses. 58.2% of doctors held a bachelor's degree compared with 45.4% of nurses, while 48.3% of nurses held a junior college degree compared with 25.7% of doctors. Higher levels of professional title and registration in general practice were found in doctors compared with nurses. The proportions of NCDs' category, NCDs-related roles and tasks, NCDs-related training contents and forms that CHWs have attend and hoped to gain more were significantly different between doctors and nurses (P < 0.001). In general, the proportions in nurses were much lower than those of doctors (P < 0.05). The top five diseases managed by CHWs were hypertension, diabetes, cerebrovascular disease, chronic respiratory diseases and mental diseases. The five most reported roles performed among doctors included the distribution of health education (91.4%), following up (85.9%), establishing archives (71.3%), medicine adjustment (64.7%) and treatment implementation (52.0%). The top three diseases managed by nurses were same with doctors. The top four and five tasks were contact with patients or health services (39.6%) and referral (16.6%) in nurses. Most CHWs had received primary and common diseases-related trainings, but they had few opportunities to study in a tertiary hospital (40.4% in doctors and 20.9% in nurses, respectively), attend domestic academic conferences (26.9% in doctors vs. 9.7% in nurses), and take part in training courses (44.9% in nurses). CHWs hoped that the above-discussed training contents and forms could be provided more in the future. Besides basic skills related trainings, some specific skills related trainings should be strengthened.

CONCLUSION

The qualifications in doctors were much better than those of nurses. The roles performed by CHWs in NCDs management are varied form common and frequent disease management to subsequent follow up and supervision. CHWs hope to receive more desired and oriented trainings. There is a need for building capacity of CHWs, optimizing and defining CHWs' role, facilitating postgraduate medical education support and strengthening multidisciplinary collaboration would be effective in NCDs management.

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

Background

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

Objectives

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

Methods

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

Results

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

Conclusion

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

"We are their eyes and ears here on the ground, yet they do not appreciate us"-Factors influencing the performance of Kenyan community health volunteers working in urban informal settlements

This study explored factors that influence CHV performance in urban informal settlements (UIS) within Nairobi Kenya and ways in which CHVs can be supported to enhance their wellbeing and strengthen community strategies. The study was undertaken in two UIS within Nairobi County. Thirteen focus group discussions and three key informant interviews were conducted with a range of respondents. Various topics covering the design of the Community Health Strategy (CHS) and broader contextual factors that affect CHVs' performance, were discussed and data analysed using a framework analysis approach. The key programme design factors identified as influencing the performance of CHVs working in UIS included: CHV recruitment; training; availability of supplies and resources; and remuneration of CHVs. Health system factors that influenced CHVs performance included: nature of relationship between healthcare workers at local referral facilities and community members; availability of services and perceived corruption at referral facilities; and CHV referral outside of the local health facility. Whereas the broader contextual factors that affected CHV performance included: demand for material or financial support; perceived corruption in community programmes; and neighbourhood insecurity. These findings suggest that CHVs working in UIS in Kenya face a myriad of challenges that impact their wellbeing and performance. Therefore, to enhance CHVs' well-being and improve their performance, the following should be considered: adequate and timely remuneration for CHVs, appropriate holistic training, adequate supportive supervision, and ensuring a satisfactory supply of resources and supplies. Additionally, at the facility level, healthcare workers should be trained on appropriate and respectful relations with both the community and the CHVs, clarity of roles and scope of work, ensure availability of services, and safeguard against corrupt practices in public health facilities. Lastly, there's a need for improved and adequate security measures at the community level, to ensure safety of CHVs as they undertake their roles.

The Association Between Work Environment, Work Attitudes, and Turnover Intentions Among Geriatric Social Workers in China

The psychological state of geriatric social workers affects the intention to leave and thus the quality of services provided to older adults. This study explored the relationship between the work environment, work attitudes, and turnover intentions of geriatric social workers. This study obtained an analytic sample comprising 999 geriatric social workers from the 2019 Longitudinal Study of Social Work in China. Multivariate regression techniques combined with a mediation analysis was performed to explore the relationships. The study results provided preliminary evidence on the complex associations between and among work environment, work attitudes, and turnover intentions of geriatric social workers in China. We demonstrated that perceived organizational support reduced the turnover intentions of geriatric social workers through increased collective psychological ownership and reduced burnout. Regular inter- and intra-agency communication between social workers and their supervisors and colleagues have important roles in reducing turnover by enhancing support and emotional commitment to organizations. Policy decision-makers are suggested to clearly define the roles and responsibilities of geriatric social works to release their administrative burdens, which may help to reduce their burnout level and improve the stability of the geriatric social work force.

A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi

INTRODUCTION

Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi.

METHODS

We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks.

RESULTS

We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05).

CONCLUSION

This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.

Community health workers' perspectives on integrating into school settings to support student health

Introduction

While schools represent key venues for supporting health, they continue to experience gaps in health resources. The integration of community health workers (CHWs) into schools has the potential to supplement these resources but has been underexplored. This study is the first to examine perspectives of experienced CHWs about how CHWs can be applied in school settings to support student health.

Methods

This qualitative study involved conducting semi-structured interviews focused on implementation of CHWs in schools with individuals who held positions aligned with the CHW scope of work. De-identified transcripts were analyzed, and codes were organized into domains and themes.

Results

Among 14 participants, seven domains emerged about the implementation of CHWs in schools: roles and responsibilities, collaborations, steps for integration, characteristics of successful CHWs, training, assessment, and potential challenges. Participants shared various potential responsibilities of school-based CHWs, including educating on health topics, addressing social determinants of health, and supporting chronic disease management. Participants emphasized the importance of CHWs building trusting relationships with the school community and identified internal and external collaborations integral to the success of CHWs. Specifically, participants indicated CHWs and schools should together determine CHWs' responsibilities, familiarize CHWs with the school population, introduce CHWs to the school community, and establish support systems for CHWs. Participants identified key characteristics of school-based CHWs, including having familiarity with the broader community, relevant work experience, essential professional skills, and specific personal qualities. Participants highlighted trainings relevant to school-based CHWs, including CHW core skills and health topics. To assess CHWs' impact, participants proposed utilizing evaluation tools, documenting interactions with students, and observing indicators of success within schools. Participants also identified challenges for school-based CHWs to overcome, including pushback from the school community and difficulties related to the scope of work.

Discussion

This study identified how CHWs can have a valuable role in supporting student health and the findings can help inform models to integrate CHWs to ensure healthy school environments.

Addressing Training Gaps: A Competency-Based, Telehealth Training Initiative for Community Health Workers

Background

To overcome vast variations in Community Health Worker (CHW) training, investigators for the CHW Core Consensus Project (CCCP) derived three types of CHW (Category 1, 2, 3) and established competencies for each category. However, studies are needed that implement these competencies in real-world settings.

Objective

Using the six competency domains of the CCCP as a theoretical backbone, we developed and evaluated a training for Category 1 CHWs, individuals whose focus is on community outreach and advocacy.

Methods

We developed five telehealth-based, bilingual (Spanish/English) training sessions and implemented them among Category 1 Latino(a) CHWs. We measured the number of CHWs who achieved ≥70% correct on a domain-based posttest, attendance, and qualitative feedback.

Results

All (18/18) CHWs achieved at least 70% on the posttest (mean: 93.7%; range 73.3-100%). Training attendance was 98.9%. Using a six-point scale, CHWs reported high levels of satisfaction overall (5.72 ± 0.57/6.0), with telehealth (5.72 ± 0.58/6.0), effectiveness of teaching strategies/methods (5.89 ± 0.32/6.0), achieving training objectives (5.96 ± 0.15/6.0), knowledge improvement (5.72 ± 0.57/6.0), and interest (5.78 ± 0.43/6.0).

Conclusion

We successfully developed and evaluated a bilingual training program for Category 1 CHWs to address core competency gaps. High CHW attendance reinforces the value of telehealth modalities and their potential to increase the reach for CHW training. To overcome gaps in chronic disease training, investigations are needed to address additional CHW trainings.

Trial Registration

NCT04835493.

Predictors of burnout, compassion fatigue, and compassion satisfaction experienced by community health workers offering maternal and infant services in New York State

Although burnout has been increasingly well studied among medical (nurses, physicians, residents) and mental health providers (psychologists, psychiatrists, social workers), there continues to be a lack of attention on the well-being of community-based providers, such as Community Health Workers (CHWs), within the United States. Using cross-sectional data from 75 CHWs employed in 14 agencies funded through the Maternal and Infant Community Health Collaboratives Initiative (MICHC) in New York, our study examined predictors (anxiety, physical health, adverse childhood experiences, job satisfaction, role certainty, demographic and work characteristics) of burnout, compassion fatigue (CF) and compassion satisfaction (CS). Descriptive statistics were used to characterize our sample and linear regression was employed to investigate the correlates of burnout, CF and CS. Results indicated that CHWs with higher levels of anxiety and lower job satisfaction were more likely to have higher burnout scores. CHWs with higher levels of anxiety, lower job satisfaction and fewer days of poorer health were more likely to report higher CF. Those who worked more than 35 h per week were less likely to report higher CS. The study provides recommendations for organizational-level interventions to address risk factors of burnout and CF and promote CS among CHWs, such as bolstering supervision, encouraging greater communication, offering recognition/appreciation of CHWs and creating opportunities for self-care. Findings should be considered when designing organizational-level preventive measures that mitigate burnout and CF and promote CS.

Effects of timed and targeted counselling by community health workers on maternal and household practices, and pregnancy and newborn outcomes in rural Uganda

INTRODUCTION

Pregnancy and birth-related complications claim the lives of millions of women and newborns every year. Improving their survival chances remains an urgent global challenge, including in Uganda. Community health workers (CHWs) play a crucial role in bridging the gap between the community and the official health system in Uganda. Timed and targeted Counselling (ttC) is an individual-level behavioral change communication method used by CHWs, aimed at pregnant women and caregivers of children under the age of two.

AIM

This study examined whether the implementation of the ttC intervention by the CHWs was associated with improved household practices and outcomes during the pregnancy and newborn period.

METHODS

A multi-stage sampling technique was employed with a total of 749 participants in the intervention group (ttC intervention), and 744 participants in the control group (no ttC). Data on quality of maternal and household antenatal care (ANC) and essential newborn care (ENC) practices, as well as on pregnancy and newborn outcomes were collected through questionnaires from May 2018 to May 2020. McNemar's Chi-square tests were used to compare outcomes before and after implementation, and between the intervention and control group.

RESULTS

Results showed that, compared to baseline, ttC contributed significantly to the demand for quality of service during ANC, ENC and partner involvement in maternal and newborn health. In comparison to the control group, the ttC group showed significantly higher early ANC attendance rates and higher quality of ANC and ENC.

CONCLUSION

ttC is a comprehensive, goal-driven approach that seems to contribute to the improvement of quality of maternal and household practices, and pregnancy and newborn outcomes in Uganda.

TRIAL REGISTRATION

PACTR, PACTR202002812123868, registered on 25 February 2020, http://www.pactr.org/PACTR202002812123868.

The effect of supervision on community health workers' effectiveness with households in rural South Africa: A cluster randomized controlled trial

BACKGROUND

Community health workers (CHWs) can supplement professional medical providers, especially in rural settings where resources are particularly scarce. Yet, outcomes of studies evaluating CHWs effectiveness have been highly variable and lack impact when scaled nationally. This study examines if child and maternal outcomes are better when existing government CHWs, who are perinatal home visitors, receive ongoing enhanced supervision and monitoring, compared to standard care.

METHODS AND FINDINGS

A cluster randomized controlled effectiveness trial was conducted comparing outcomes over 2 years when different supervision and support are provided. Primary health clinics were randomized by clinic to receive monitoring and supervision from either (1) existing supervisors (Standard Care (SC); n = 4 clinics, 23 CHWs, 392 mothers); or (2) supervisors from a nongovernmental organization that provided enhanced monitoring and supervision (Accountable Care [AC]; n = 4 clinic areas, 20 CHWs, 423 mothers). Assessments were conducted during pregnancy and at 3, 6, 15, and 24 months post-birth with high retention rates (76% to 86%). The primary outcome was the number of statistically significant intervention effects among 13 outcomes of interest; this approach allowed us to evaluate the intervention holistically while accounting for correlation among the 13 outcomes and considering multiple comparisons. The observed benefits were not statistically significant and did not show the AC's efficacy over the SC. Only the antiretroviral (ARV) adherence effect met the significance threshold established a priori (SC mean 2.3, AC mean 2.9, p < 0.025; 95% CI = [0.157, 1.576]). However, for 11 of the 13 outcomes, we observed an improvement in the AC compared to the SC. While the observed outcomes were not statistically significant, benefits were observed for 4 outcomes: increasing breastfeeding for 6 months, reducing malnutrition, increasing ARV adherence, and improving developmental milestones. The major study limitation was utilizing existing CHWs and being limited to a sample of 8 clinics. There were no major study-related adverse events.

CONCLUSIONS

Supervision and monitoring were insufficient to improve CHWs' impact on maternal and child outcomes. Alternative strategies for staff recruitment and narrowing the intervention outcomes to the specific local community problems are needed for consistently high impact.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02957799.

Community Health Worker Use of Smart Devices for Health Promotion: Scoping Review

BACKGROUND

Community health workers (CHWs) have become essential to the promotion of healthy behaviors, yet their work is complicated by challenges both within and beyond their control. These challenges include resistance to the change of existing behaviors, disbelief of health messages, limited community health literacy, insufficient CHW communication skills and knowledge, lack of community interest and respect for CHWs, and CHWs' lack of adequate supplies. The rising penetration of "smart" technology (eg, smartphones and tablets) in low- and middle-income countries facilitates the use of portable electronic devices in the field.

OBJECTIVE

This scoping review examines to what extent mobile health in the form of smart devices may enhance the delivery of public health messages in CHW-client interactions, thereby addressing the aforementioned challenges and inducing client behavior change.

METHODS

We conducted a structured search of the PubMed and LILACS databases using subject heading terms in 4 categories: technology user, technology device, use of technology, and outcome. Eligibility criteria included publication since January 2007, CHWs delivering a health message aided by a smart device, and face-to-face communication between CHWs and clients. Eligible studies were analyzed qualitatively using a modified version of the Partners in Health conceptual framework.

RESULTS

We identified 12 eligible studies, 10 (83%) of which used qualitative or mixed methods approaches. We found that smart devices mitigate challenges encountered by CHWs by improving their knowledge, motivation, and creativity (eg, through self-made videos); their status within the community; and the credibility of their health messages. The technology stimulated interest in both CHWs and clients-and sometimes even in bystanders and neighbors. Media content produced locally or reflecting local customs was strongly embraced. Yet, the effect of smart devices on the quality of CHW-client interactions was inconclusive. Interactions suffered as CHWs were tempted to replace educational conversations with clients by passively watching video content. Furthermore, a series of technical difficulties experienced especially by older and less educated CHWs compromised some of the advantages brought about by mobile devices. Adequate CHW training ameliorated these difficulties. Only 1 study (8%) considered client health behavior change as an end point, thus revealing a major research gap.

CONCLUSIONS

Smart mobile devices may augment CHWs' field performance and enhance face-to-face interactions with clients, yet they also generate new challenges. The available evidence is scarce, mostly qualitative, and focused on a limited range of health outcomes. Future research should include larger-scale interventions across a wide range of health outcomes and feature client health behavior change as an end point.

Effect of home visits by community health workers on complementary feeding practices among caregivers of children aged 6-23 months in 10 districts of Bangladesh

Background

Suboptimal complementary feeding contributes to undernutrition in children aged 6-23 months in low- and middle-income countries like Bangladesh. Multifaceted interventions have been taken to improve complementary feeding practices, but there is limited evidence about the effect of home visits by community health workers (CHWs) on complementary feeding practices of the caregivers of children.

Methods

We collated data from the baseline and the corresponding follow-up survey done as part of an evaluation of Bangladesh Maternal, Infant and Young Child Nutrition (MIYCN) programme. We collected data on complementary feeding practices using a 24-h recall questionnaire. Age-appropriate dietary diversity, minimum meal frequency, and minimum acceptable diet were assessed based on recommended food consumption as per child's age. To understand the effect of CHWs' visits on complementary feeding practices, we performed Generalized Estimating Equation (GEE) procedure for dealing with correlated data and adjusted other covariates.

Results

A total of 758 and 745 caregivers of children aged 6-23 months participated in the baseline and follow-up survey, respectively. Complementary feeding practices were improved in 1 year of programme implementation; dietary diversity increased from 46 to 54%, minimum meal frequency from 82 to 91%, and minimum acceptable diet from 41 to 53%. Caregivers of children who had received the visit of CHWs in the last 12 months prior to the day of the follow-up survey were more likely (AOR 1.51; 95% CI 1.10-2.10) to maintain dietary diversity in their children's feeding practices than the caregivers who had not received a CHW visit in the last 12 months. The likelihood of maintaining a minimum acceptable diet in feeding practices was 1.57 times higher (AOR 1.57; 95% CI 1.14-2.17) among the caregivers who were exposed to the visits of the CHWs in the last 12 months compared to the caregivers who were not exposed to the CHW's visits in the last 12 months.

Conclusion

Integration of promotional activities of complementary feeding practices into the mainstream nutrition programme can be instrumental in optimizing complementary feeding practices among the caregivers of the under-five children. However, home visits by CHWs should be prioritized in such an integrated programme.

Implementation and scaling-up of an effective mHealth intervention to increase adherence to triage of HPV-positive women (ATICA study): perceptions of health decision-makers and health-care providers

BACKGROUND

The ATICA study was a Hybrid I type randomized effectiveness-implementation trial that demonstrated effectiveness of a multicomponent mHealth intervention (Up to four SMS messages sent to HPV-positive women, and one SMS message to CHWs to prompt a visit of women with no triage Pap 60 days after a positive-test), to increase adherence to triage of HPV positive women (ATICA Study). We report data on perceptions of health decision-makers and health-care providers regarding the intervention implementation and scaling-up.

METHODS

A qualitative study was carried out based on individual, semi-structured interviews with health decision-makers (n = 10) and health-care providers (n = 10). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and the maintenance dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.

RESULTS

Both health-care providers and decision-makers had a positive assessment of the intervention through most included constructs: knowledge of the intervention, intervention source, design quality, adaptability, compatibility, access to knowledge and information, relative advantage, women's needs, and relative priority. However, some potential barriers were also identified including: complexity, leadership engagement, external policies, economic cost, women needs and maintenance. Stakeholders conditioned the strategy's sustainability to the political commitment of national and provincial health authorities to prioritize cervical cancer prevention, and to the establishment of the ATICA strategy as a programmatic line of work by health authorities. They also highlighted the need to ensure, above all, that there was staff to take Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-tests.

CONCLUSION

Health decision-makers and health-care providers had a positive perception regarding implementation of the multicomponent mHealth intervention designed to increase adherence to triage among women with HPV self-collected tests. This increases the potential for a successful scaling-up of the intervention, with great implications not only for Argentina but also for middle and low-income countries considering using mHealth interventions to enhance the cervical screening/follow-up/treatment process.

The effect of a large-scale water, sanitation and hygiene intervention in Bangladesh on knowledge, behaviour and health: Findings from an endline programme evaluation

OBJECTIVES

The Sanitation, Hygiene Education and Water Supply in Bangladesh Programme (SHEWA-B) was a 5-year intervention aiming to improve water, sanitation and hygiene (WASH) practices among 20 million rural residents through community hygiene promoters. This analysis evaluates the impact of SHEWA-B on knowledge, behaviour and childhood diarrhoea outcomes.

METHODS

The evaluation included repeated cross-sectional surveys and health surveillance in matched cohorts in intervention and control clusters. Cross-sectional surveys and structured observations at baseline, midline, and endline assessed the availability of WASH technology, caregiver knowledge and behaviour. Fieldworkers collected monthly health data in a subset of control and intervention households to determine the prevalence of diarrhoea.

RESULTS

Of 5091 households surveyed, participants residing in intervention clusters showed minimal improvements in knowledge, reported behaviour, or use of WASH technology compared to the control clusters. During structured observations, intervention households increased more than control households at handwashing before preparing food and after cleaning a baby's anus when comparing endline to baseline, but these changes were not seen when comparing endline to the midline. The prevalence of childhood diarrhoea remained similar in both groups before (10.2% in intervention, 10.0% in control) and after (8.8% in intervention, 11.7% in control) midline changes were made to improve the intervention. Intervention clusters showed no improvement in diarrhoea over time compared to control clusters.

CONCLUSIONS

SHEWA-B's community-based WASH promotion did not yield the intended impact on knowledge, behaviour or health. Greater priority should be given to approaches that have demonstrated effectiveness. Including rigorous evaluations would broaden the evidence base to support and improve large-scale programmes.

Assessing community health workers' time allocation for a cervical cancer screening and treatment intervention in Malawi: a time and motion study

BACKGROUND

Community health workers (CHWs) are essential field-based personnel and increasingly used to deliver priority interventions to achieve universal health coverage. Existing literature allude to the potential for detrimental effects of multi-tasking CHWs. This study objective was to assess the impact of integrating cervical cancer screening and prevention therapy (CCSPT) with family planning (FP) on time utilization among CHWs.

METHODS

A time and motion study was conducted in 7 health facilities in Malawi. Data was collected at baseline between October-July 2019, and 12 months after CCSPT implementation between July and August 2021. CHWs trained to deliver CCSPT were continuously observed in real time while their activities were timed by independent observers. We used paired sample t-test to assess pre-post differences in average hours CHWs spent on the following key activities, before and after CCSPT implementation: clinical and preventive care; administration; FP; and non-work-related tasks. Regression models were used to ascertain impact of CCSPT on average durations CHWs spent on key activities.

RESULTS

Thirty-seven (n = 37) CHWs were observed. Their mean age and years of experience were 42 and 17, respectively. Overall, CHWs were observed for 323 hours (inter quartile range: 2.8-5.5). Compared with the period before CCSPT, the proportion of hours CHWs spent on clinical and preventive care, administration and non-work-related activities were reduced by 13.7, 8.7 and 34.6%, respectively. CHWs spent 75% more time on FP services after CCSPT integration relative to the period before CCSPT. The provision of CCSPT resulted in less time that CHWs devoted towards clinical and preventive care but this reduction was not significant. Following CCPST, CHWs spent significantly few hours on non-work-related activities.

CONCLUSION

Introduction of CCSPT was not very detrimental to pre-existing community services. CHWs managed their time ensuring additional efforts required for CCSPT were not at the expense of essential activities. The programming and policy implications are that multi-tasking CHWs with CCSPT will not have substantial opportunity costs.

Not knowing enough, not having enough, not feeling wanted: Challenges of community health workers providing maternal and newborn services in Africa and Asia

BACKGROUND

Community health workers (CHWs) have been identified as a critical bridge to reaching many communities with essential health services based on their social and geographical proximity to community residents. However, various challenges limit their performance, especially in low-and middle-income countries. With the view to guiding global and local stakeholders on how best to support CHWs, this study explored common challenges of different CHW cadres in various contexts.

METHODS

We conducted 36 focus group discussions and 131 key informant interviews in Bangladesh, India, Kenya, Malawi, and Nigeria. The study covered 10 CHW cadres grouped into Level 1 and Level 2 health paraprofessionals based on education and training duration, with the latter having a longer engagement. Data were analysed using thematic analysis.

RESULTS

We identified three critical challenges of CHWs. First, inadequate knowledge affected service delivery and raised questions about the quality of CHW services. CHWs' insufficient knowledge was partly explained by inadequate training opportunities and the inability to apply new knowledge due to equipment unavailability. Second, their capacity for service coverage was limited by a low level of infrastructural support, including lack of accommodation for Level 2 paraprofessional CHWs, inadequate supplies, and lack of transportation facilities to convey women in labour. Third, the social dimension relating to the acceptance of CHWs' services was not guaranteed due to local socio-cultural beliefs, CHW demographic characteristics such as sex, and time conflict between CHWs' health activities and community members' daily routines.

CONCLUSION

To optimise the performance of CHWs in LMICs, pertinent stakeholders, including from the public and third sectors, require a holistic approach that addresses health system challenges relating to training and structural support while meaningfully engaging the community to implement social interventions that enhance acceptance of CHWs and their services.

"They are our eyes outside there in the community": Implementing enhanced training, management and monitoring of South Africa’s ward-based primary healthcare outreach teams

Introduction

In 2018, South Africa’s National Department of Health provided additional resources for ward-based primary healthcare outreach teams (OT) with support from the U.S. President’s Emergency Plan for AIDS Relief. The intervention package included a new training curriculum, enhanced staffing, revised management and supervisory structures, and more intensive monitoring and evaluation (M&E). The goal was to strengthen OT and their impact on both primary healthcare and HIV-specific services. We conducted a process evaluation of this intervention package during its second year and examined implementation successes and challenges.

Methods

We conducted a mixed-methods evaluation at 20 purposively selected facilities in Bojanala and City of Tshwane districts, including surveys with 222 community health workers (CHWs) and outreach team leaders (OTLs); key informant interviews and online surveys with 28 policy and program stakeholders; 70 in-depth interviews with health facility staff; 20 focus group discussions with 194 CHWs; 20 structured health facility assessments; directly-observed time-motion studies; and review of program documents.

Results

Most participants highlighted the hiring and training of CHWs and OTLs as a key implementation success because this had partially alleviated staffing shortages and helped clarify CHWs’ and OTLs’ responsibilities and supervisory structures. The new monitoring tools were welcomed for their potential to improve data collection and program tracking. However, participants highlighted many program challenges: short-lived gains in CHWs’ knowledge and skills due to lack of ongoing training and mentoring; insufficient integration of OT into health facility management structures; persistent shortages of equipment, supplies, transportation, and workspace for CHWs; and insufficient remuneration for staff.

Conclusion

Strengthening and expanding CHW programs, such as OT, requires intensive support and continuous investments. To sustain improvements in training, supervision, and job satisfaction, CHWs must be equipped with needed resources, provided with ongoing supportive supervision, and strengthened by optimized program management, monitoring and processes.

Building a public health workforce for a university campus during a pandemic using a practicum framework: Design and outcomes

Background

The reopening of college and university campuses was seen as presenting a high risk for transmission of COVID-19. Thus, these institutions faced with a new public health challenge never heretofore faced on this scale. To magnify the problem, they needed to rapidly develop and implement re-opening plans in an environment filled with uncertainty and for a population that was significantly less likely to observe COVID-19 mitigation behaviors. In response, within three weeks of opening, as part of its COVID-19 public health strategy, a West Coast university created and trained a public health workforce comprised of 282 undergraduates tasked with encouraging compliance with COVID-19 mitigating healthy behaviors.

Main objectives

This paper describes the use and outcomes of a practicum framework to quickly create a university-based public health workforce. It addresses two questions: (1) Using a practicum framework, what are important considerations in designing and building a public health workforce for a university campus? and (2) What are the benefits to the workforce in terms of public health education and professional growth?

Methods

Program administrative data were used to describe the workforce and their learning outcomes.

Results

The majority of students indicated that through the practicum, they learned new skills/developed new attitudes (71.7%) and became aware of their own strengths and opportunities for professional growth (73.7%). The types of new skills and attitudes learned included communication (49.2%), conflict management (20.4%), time management (7.5%), and open-mindedness/less judgmental attitude (14.6%). In terms of public health, they gained an understanding of infectious disease prevention (40.9%) that is multi-disciplinary (20.5%), and involves a community effort (36.8%).

Conclusions

These findings demonstrate an effective way of rapidly addressing public health concerns that allowed for on the job training and opportunities for young adults to learn and grow. The practicum framework allowed the expeditious development of a public health workforce that ensured a fit between student interests and the role. This led to high retention with the majority of students continuing into the winter quarter. Only 5% of students reported not being satisfied with their position. None of the students contracted job-related COVID-19. The role gave students a sense of purpose during the pandemic’s uncertain times that helped to protect them from the negative effects of stress. The practicum structure and support fostered a safe environment in which students were able to feel part of the larger community while gaining valuable work experience and skills and serve their community.

Impact of Job Satisfaction and Social Support on Job Performance Among Primary Care Providers in Northeast China: A Cross-Sectional Study

Background

Primary health care institutions face major challenges in maintaining the accessibility and affordability of health services. This requires primary care providers to change and improve their performance. Therefore, Study on the job performance is conducive to improve the quality of primary health care services and the sense of access of primary care providers.To understand the current status of job performance among primary care providers in Heilongjiang Province, China, and explore the impact of job satisfaction and social support on job performance, further to improve the job performance of primary care providers and ensure the stable development of primary health services.

Methods

A stratified sampling method was adopted to select 1,500 primary care providers from seven cities in Heilongjiang Province, China, using the gross domestic product development level of each city as a basis. A questionnaire survey was conducted (effective response rate was 85.8%) by using sociodemographic factors, job satisfaction scale, social support scale and job performance scale. One-way ANOVA or independent sample t-test was used to analyze the differences of demographic factors on job performance. Pearson correlation analysis was used to measure relationship between job satisfaction, social support and job performance. Hierarchical linear regression was used to analyze the relevant influencing factors associated with job performance among primary care providers.

Results

Among the primary care providers who participated in this survey, the mean job performance score was 22.189 (SD = 7.695). The job performance of primary care providers was positively correlated with job satisfaction (r=0.574, p < 0.001), and was also positively correlated with social support (r = 0.534, p < 0.001). Model 3 showed that job satisfaction (β = 0.299, p < 0.001) and social support (β = 0.149, p <0.001) are positive predictors of job performance, respectively. Moreover, the regression relationship explained that 37.6% for the variation of the dependent variable.

Conclusions

The job performance of primary care providers in Heilongjiang province is relatively low. Job satisfaction and social support are the relevant factors affecting the job performance of primary care providers. It is necessary to provide assistance to primary care providers in terms of family, organization, society, policy, etc., to improve their job performance, and to better provide high-quality health services to the grassroots.

The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions

Introduction

Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes.

Methods

We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices.

Results

The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings.

Conclusion

The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.

Infection preparedness of community health workers: implications for maternal and neonatal health services in Pakistan

AIM

This study aimed to (i) identify community health workers' (CHWs) perceived satisfaction for maternal and neonatal health services, with respect to (1) socio-demographic characteristics; (2) coronavirus preparedness; (3) coronavirus responsiveness; and (4) employee satisfaction and (ii) investigate the interplay among study variables to identify the role of direct effects and mediation.

BACKGROUND

Women CHWs are salient providers for maternal and neonatal services at the primary level, especially in conservative regions. Service delivery is a valuable indicator for mother and newborn wellbeing. There is need for empirical evidence to understand how CHWs may be supported in delivering maternal and neonatal health services during pandemics.

METHODS

Bivariate regression was used to identify the lower odds for CHWs' perceived satisfaction for maternal and neonatal health services. In addition, structural equation modeling was used to investigate if coronavirus responsiveness and employee satisfaction as mediating variables influence the relationship between coronavirus preparedness and maternal and neonatal health services. Data were collected telephonically from 350 CHWs. The sample was representative of 35 districts of Punjab, which is the most populated province in the country.

FINDINGS

We found thirty predictors with respect to coronavirus preparedness, coronavirus responsiveness and employee satisfaction which contribute to lower odds of satisfaction for maternal and neonatal health services. We also found that coronavirus preparedness has a direct effect on maternal and neonatal health service satisfaction (β = .242, P < .001) and an indirect effect on maternal health satisfaction (β = .242, P < .001) via the mediation of employee satisfaction. We conclude with four critical recommendations to support CHWs in delivering optimal services, comprising of education and training, operational support, public acceptance, and employee support and benefits. The findings are important for the planning of primary health services and governance support for CHWs and poor women clients in Pakistan and other developing countries.

Tuberculosis treatment management in primary healthcare sectors: a mixed-methods study investigating delivery status and barriers from organisational and patient perspectives

OBJECTIVE

Tuberculosis (TB) treatment management services (TTMSs) are crucial for improving patient treatment adherence. Under the TB integrated control model in China, healthcare workers (HCWs) in the primary healthcare (PHC) sectors are responsible for TTMS delivery. This mixed-method study aimed to explore the status of and barriers to TTMS delivery faced by HCWs in PHC sectors from the health organisational and patient perspectives.

DESIGN

We completed a questionnaire survey of 261 TB healthcare workers (TB HCWs) and 459 patients with TB in the PHC sector and conducted 20 semistructured interviews with health organisational leaders, TB HCWs and patients with TB. SPSS V.22.0 and the framework approach were used for data analysis.

SETTING

PHC sectors in Southwest China.

RESULTS

Our results showed that TTMS delivery rate by HCWs in PHC sectors was <90% (88.4%) on average, and the delivery rates of intensive and continuation phase directly observed therapy (DOT) were only 54.7% and 53.0%, respectively. HCWs with high work satisfaction and junior titles were more likely to deliver first-time home visits and DOT services. Our results suggest that barriers to TTMS delivery at the organisational level include limited patient-centred approaches, inadequate resources and incentives, insufficient training, poor cross-sectional coordination, and strict performance assessment. At the patient level, barriers include low socioeconomic status, poor health literacy and TB-related social stigma.

CONCLUSION

TTMSs in Southwest China still need further improvement, and this study highlighted specific barriers to TTMS delivery in the PHC sector. Comprehensive measures are urgently needed to address these barriers at the organisational and patient levels to promote TB control in Southwest China.

“Mothers will be lucky if utmost receive a single scheduled postnatal home visit”: An exploratory qualitative study, Northern Ethiopia

Background

Postnatal home visits (PNHVs) have been endorsed as strategy for delivery of postnatal care (PNC) to reduce newborn mortality and improve maternal outcomes. Despite the important role of the Health Extension Workers (HEWs) in improving the overall healthcare coverage, PNHV remains as a missed opportunity in rural Ethiopia. Thus, this study aimed to explore the barriers and facilitators of scheduled postnatal home visits in Northern Ethiopia.

Methods

We conducted an exploratory qualitative study on a total of 16 in-depth interviews with HEWs and mothers who gave birth one year prior to the study. In addition, focus group discussions were conducted with HEWs and key informant interviews were conducted with women development group leaders, supervisors, and healthcare authorities from April to June 2019 in two rural districts of Northern Ethiopia. Discussions and interviews were audio recorded and transcribed verbatim in the local language (Tigrigna) and translated into English. The translated scripts were thematically coded using Atlas ti scientific software. Field notes were also taken during the discussion and while conducting the interviews.

Results

Health system factors, community context, and individual level factors were considered as the barriers and facilitators of scheduled PNHVs. Leadership, governance, management, support and supervision, referral linkages, overwhelming workload, capacity building, logistics and supplies are the major sub-themes identified as health system factors. Physical characteristics like geographical location and topography, distance, and coverage of the catchment; and community support and participation like support from women’s development groups (WDGs), awareness of the community on the presence of the service and cultural and traditional beliefs were community contexts that affect PNHVs. Self-motivation to support and intrinsic job satisfaction were individual level factors that were considered as barriers and facilitators.

Conclusion

The finding of this study suggested that the major barriers of postnatal home visits were poor attention of healthcare authorities of the government bodies, lack of effective supervision, poor functional linkages, inadequate logistics and supplies, unrealistic catchment area coverage, poor community participation and support, and lack of motivation of HEWs. Henceforth, to achieve the scheduled PNHV in rural Ethiopia, there should be strong political commitment and healthcare authorities should provide attention to postnatal care both at facility and home with a strong controlling system.

Effectiveness of four interventions in improving community health workers' performance in western Kenya: a quasi-experimental difference-in-differences study using a longitudinal data

Background:

Community health workers (CHWs) are up-front health workers delivering the most effective life-saving health services to communities. They are the key driver to achieve Universal Health Coverage. However, maintaining CHWs’ performance is one of the challenges in sustaining their effectiveness. This article assessed the effectiveness of the four interventions and their combinations on the CHWs’ performance in terms of health knowledge, job satisfaction, and household coverage.

Methods:

We used the longitudinal survey data collected in western Kenya. Our study participants were the representative of all CHWs working in the four districts, Kenya. The four types of interventions were composed of a basic core intervention (i.e., refresher training with/without defaulter tracing) and three supplementary interventions (i.e., provision of a bicycle, frequent supportive supervision, and financial incentives). We performed the three fixed-effect models to assess the effectiveness of the four interventions and their combinations on the three performance indicators.

Results:

Three single and combination interventions significantly increased CHWs’ health knowledge: refresher training only [Coef.: 48.43, 95% CI: 42.09–54.76, P < 0.001]; refresher training plus defaulter-tracing [Coef.: 38.80, 95% CI: 32.71–44.90, P < 0.001]; combination of refresher training plus defaulter-tracing and frequent supervision [Coef.: 17.02, 95% CI: 7.90–26.15, P < 0.001]. Financial support was the only intervention that significantly increased job satisfaction among CHWs [Coef.: 4.97, 95% CI: 0.20–9.75, P = 0.041]. There was no single intervention that significantly increased household coverage. Yet, the combinations of the interventions significantly increased household coverage.

Conclusions:

There was no single intervention to improve all the aspects of CHWs’ performance. The refresher training significantly improved their health knowledge, while financial incentive enhanced the level of their job satisfaction. The combinations of regular refresher training and other intervention(s) are the recommended as the effective interventions in improving and further sustaining CHWs’ performance.

MS. Assessment of Workload of ASHAs: A Multi-stakeholder Perspective Study for Task-sharing and Task-shifting

The Accredited Social Health Activist (ASHA) programme has proven to be cost-effective and successful in addressing the growing shortage of health workers and reaching the vulnerable. ASHA’s contribution towards the improvement in maternal and child health and other health programmes at the community level is reported and acknowledged widely in literature. However, nearly 16 years into the introduction of ASHA, challenges in terms of workload, fatigue, poor work–life balance and low levels of compensation have emerged.

Aim:

To assess the workload on ASHAs, impact of their responsibilities on their quality of life and the potential for structured task sharing/shifting among other healthcare workers.

Methodology:

The study used a mixed-method approach with data and source triangulation. A multi-stage random sampling method was used to collect the data. Qualitative research was carried out to explore ASHAs’ and stakeholders’ perspectives, and a thematic analysis was undertaken using NVivo-12. ASHAs’ quality of life was also measured using the World Health Organization Quality of Life (WHO QOL)-BREF. The study was carried out in three districts of Karnataka: Mysuru, Raichur and Koppala.

Results:

The majority of ASHAs reported that they experience work burden in terms of population coverage, extended hours of work and additional tasks. Lack of access to transportation, inadequate support from other healthcare personnel and delayed payment of incentives add to them often feeling overworked and underpaid. The research also elicited perspectives on ASHAs’ work from different stakeholders. Findings from the study emphasise the necessity for sharing/shifting of selected tasks among other frontline health workers based on complexity and capabilities.

A Community Health Worker-Led mHealth-Enabled Diabetes Self-Management Education and Support Intervention in Rural Latino Adults: Single-Arm Feasibility Trial (Preprint)

Background

Latinos living in rural South Texas have a higher prevalence of diabetes, but their access to diabetes self-management education and support (DSMES) is limited.

Objective

We aimed to test the feasibility of a community health worker-led, mobile health (mHealth)-based DSMES intervention to reduce disparities in accessing DSMES in underserved rural Latino residents in South Texas.

Methods

This 12-week, single-arm, pre-post trial was delivered by trained community health workers to 15 adults with type 2 diabetes. The intervention consisted of digital diabetes education, self-monitoring, a cloud-based connected platform, and community health worker support. Feasibility was evaluated as retention, actual intervention use, program satisfaction, and barriers to implementation. We also explored the intervention’s effect on weight loss and hemoglobin A_1c (HbA_1c).

Results

All 15 participants were Latino (mean age 61.87 years, SD 10.67; 9/15 female, 60%). The retention rate at posttest was 14 of 15 (93%). On average, the participants completed 37 of 42 (88%) digital diabetes education lessons with 8 participants completing all lessons. Participants spent 81/91 days (89%) step tracking, 71/91 days (78%) food logging, 43/91 days (47%) blood glucose self-monitoring, and 74/91 days (81%) weight self-monitoring. The level of program satisfaction was high. On average, participants lost 3.5 (SD 3.2) kg of body weight (P=.001), while HbA_1c level remained unchanged from baseline (6.91%, SD 1.28%) to posttest (7.04%, SD 1.66%; P=.668).

Conclusions

A community health worker-led mHealth-based intervention was feasible and acceptable to improve access to DSMES services for Latino adults living in rural communities. Future randomized controlled trials are needed to test intervention efficacy on weight loss and glycemic control.

Qualitative assessment of community health workers' perspective on their motivation in community-based primary health care in rural Malawi

BACKGROUND

Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities.

METHODS

We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March-April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose.

RESULTS

Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs.

CONCLUSION

This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can  focus on enhancing motivational factors found in this study to improve the CHWs' experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.

Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation

Background

Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs.

Methods

We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards.

Results

The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support.

Conclusion

This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required.

Determining staffing standards for primary care services using workload indicators of staffing needs in the Philippines

BACKGROUND

Health services cannot be delivered without an adequate, competent health workforce. Evidence suggests a direct relationship between density of health workforce and health outcomes. The Philippines is faced with health workforce challenges including shortages, inequitable distribution and inadequate skill mix which hinder health service delivery. Evidence-based workforce planning is, therefore, critical to achieve universal health care.

METHODS

The Philippines adopted the World Health Organization's workload indicators of staffing need methodology. Using a multistage sampling method, nine regions with poor health indicators in tuberculosis, family planning, and maternal child health were identified. Physicians, nurses, midwives, and medical technologists were prioritized in the study from 89 primary care health facilities (barangay health stations, rural health units, and city health offices). Data was collected using in-depth interviews, document reviews, observations, and field visits. The workload indicators of staffing need software were used for data analysis to determine staffing requirements and analyse workforce pressure.

RESULTS

The study showed varied results in terms of staffing requirements and workload pressure across cadres and facility types. Some health facilities exhibited staff shortages and high workload pressure. Out of the 40 rural health units and city health offices, only three had the required physicians needed and 22 facilities had a shortage of physicians working under high workload pressure. Other facilities had excess staff compared to the calculated requirements. Nurses at the rural health units showed high workload pressure. Ten rural health units had no medical technologists. Midwives at barangay health stations exhibited extremely low workload pressures.

CONCLUSION

The study identifies the need for the Philippine Health System, both through the Department of Health and the local governments to efficiently optimize the available health workers by revising the services offered at the primary health care facilities. The results provide evidence for staffing requirements at various levels of care based on workloads, scope of practice and time taken to undertake specific tasks at the barangay health stations, rural health units and city health offices to be integrated into the human resources for health management systems.

Systematic review of performance-enhancing health worker supervision approaches in low- and middle-income countries

BACKGROUND

The strength of a health system-and ultimately the health of a population-depends to a large degree on health worker performance. However, insufficient support to build, manage and optimize human resources for health (HRH) in low- and middle-income countries (LMICs) results in inadequate health workforce performance, perpetuating health inequities and low-quality health services.

METHODS

The USAID-funded Human Resources for Health in 2030 Program (HRH2030) conducted a systematic review of studies documenting supervision enhancements and approaches that improved health worker performance to highlight components associated with these interventions' effectiveness. Structured by a conceptual framework to classify the inputs, processes, and results, the review assessed 57 supervision studies since 2010 in approximately 29 LMICs.

RESULTS

Of the successful supervision approaches described in the 57 studies reviewed, 44 were externally funded pilots, which is a limitation. Thirty focused on community health worker (CHW) programs. Health worker supervision was informed by health system data for 38 approaches (67%) and 22 approaches used continuous quality improvement (QI) (39%). Many successful approaches integrated digital supervision technologies (e.g., SmartPhones, mHealth applications) to support existing data systems and complement other health system activities. Few studies were adapted, scaled, or sustained, limiting reports of cost-effectiveness or impact.

CONCLUSION

Building on results from the review, to increase health worker supervision effectiveness we recommend to: integrate evidence-based, QI tools and processes; integrate digital supervision data into supervision processes; increase use of health system information and performance data when planning supervision visits to prioritize lowest-performing areas; scale and replicate successful models across service delivery areas and geographies; expand and institutionalize supervision to reach, prepare, protect, and support frontline health workers, especially during health emergencies; transition and sustain supervision efforts with domestic human and financial resources, including communities, for holistic workforce support. In conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.

An mHealth tool for community health workers to improve caregiver knowledge of child health in the Amazon: An effectiveness-implementation hybrid evaluation

When community health workers (CHWs) are effective, they can teach healthy child rearing practices in their communities and improve child health and development outcomes. An effective mHealth tool can improve the capacity of CHWs to transmit knowledge to caregivers. This article evaluates the implementation of an mHealth tool in a CHW program in the Amazon of Peru. The intervention was designed, implemented, and evaluated with the guidance of multiple implementation science tools. A Hybrid Type 3 evaluation design was used to test the effectiveness of the implementation strategies and appropriateness of the intervention. The implementation outcomes: acceptability, adoption, dosage, and fidelity were analyzed with mixed methods approach to determine if the intervention was successfully installed in the CHW program. The service outcome, knowledge scores, was analyzed with an independent samples t-test and one way ANOVA to determine the effect of the program. The implementation strategies resulted in high degrees of acceptability, adoption, and fidelity of the mHealth tool. The surveillance component of the mHealth tools was not adequately adopted. The group of caregivers that received home visits with the mHealth tool (N = 48) had significantly higher knowledge scores (+1.26 standard deviations) than those in the control group (N = 138) (t(184) = -4.39, p<0.001). The COVID-19 pandemic significantly decreased the dosage of the intervention received by the participants. The CHEST App intervention is a promising tool to improve the capacity of CHWs during their home visits. Trial registered with ISRCTN on 11/29/2018 at https://doi.org/10.1186/ISRCTN43591826.

Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.