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Ebob Besem E O M, Chestnutt EG, Donovan L, Stratil AS, Counihan H, Nkfusai CN, Hawkings H, Homolova B, Maxwell K, Baker K, Zoungrana Y, Tanue EA, Ayuk G, Modjenpa NB, Metuge A, Nganmou I, Achu D, Wanji S, Berryman E, Omam LA. Exploring existing malaria services and the feasibility of implementing community engagement approaches amongst conflict-affected communities in Cameroon: a qualitative study. Malar J 2024; 23:155. [PMID: 38769514 PMCID: PMC11107007 DOI: 10.1186/s12936-024-04934-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Cameroon is one of the countries with the highest burden of malaria. Since 2018, there has been an ongoing conflict in the country, which has reduced access to healthcare for populations in affected regions, and little is known about the impact on access to malaria services. The objective of this study was to understand the current situation regarding access to malaria services in Cameroon to inform the design of interventions to remove barriers and encourage the use of available services. METHODS A qualitative research study was carried out to understand the barriers preventing communities accessing care, the uptake of community health worker (CHW) services, and to gather perceptions on community engagement approaches, to assess whether these could be an appropriate mechanism to encourage uptake of community health worker (CHW) services. Twenty-nine focus group discussions and 11 in-depth interviews were carried out between May and July 2021 in two regions of Cameroon, Southwest and Littoral. Focus group discussions were held with CHWs and community members and semi-structured, in-depth interviews were conducted with key stakeholders including regional government staff, council staff, community leaders and community-based organisations. The data were analysed thematically; open, descriptive coding was combined with exploration of pre-determined investigative areas. RESULTS The study confirmed that access to healthcare has become increasingly challenging in conflict-affected areas. Although the Ministry of Health are providing CHWs to improve access, several barriers remain that limit uptake of these services including awareness, availability, cost, trust in competency, and supply of testing and treatment. This study found that communities were supportive of community engagement approaches, particularly the community dialogue approach. CONCLUSION Communities in conflict-affected regions of Cameroon continue to have limited access to healthcare services, in part due to poor use of CHW services provided. Community engagement approaches can be an effective way to improve the awareness and use of CHWs. However, these approaches alone will not be sufficient to resolve all the challenges faced by conflict-affected communities when accessing health and malaria services. Additional interventions are needed to increase the availability of CHWs, improve the supply of diagnostic tests and treatments and to reduce the cost of treatment for all.
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Affiliation(s)
- Margaret Ebob Besem E O
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, Cameroon
| | | | - Laura Donovan
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Ann-Sophie Stratil
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Helen Counihan
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Claude Ngwayu Nkfusai
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
- Department of Public Health, School of Nursing and Public Health, University of Kwa-Zulu Natal, Durban, South Africa
| | - Helen Hawkings
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Blanka Homolova
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
| | - Kolawole Maxwell
- Malaria Consortium Nigeria, No 33 Pope John Paul Street, Off Gana Street, Maitama, Abuja, FCT, Nigeria
| | - Kevin Baker
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK
- Karolinksa Institute, Nobels Väg 15 A, 171 77, Stockholm, Sweden
| | - Yakouba Zoungrana
- Malaria Consortium Nigeria, No 33 Pope John Paul Street, Off Gana Street, Maitama, Abuja, FCT, Nigeria
| | - Elvis Asangbeng Tanue
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, Cameroon
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
| | - Glennise Ayuk
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
| | | | - Alain Metuge
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
| | | | - Dorothy Achu
- National Malaria Control Programme, Ministry of Public Health, Yaoundé, Cameroon
| | - Samuel Wanji
- Department for Microbiology and Parasitology at the University of Buea, Buea, Cameroon
- Research Foundation in Tropical Diseases and Environment, Buea, Cameroon
| | - Elizabeth Berryman
- Malaria Consortium, The Green House, 244-254 Cambridge Heath Rd, London, E2 9DA, UK.
| | - Lundi-Anne Omam
- Reach Out Cameroon (REO), P.O Box 88, Buea, Cameroon
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Wagaba MT, Musoke D, Bagonza A, Ddamulira JB, Nalwadda CK, Orach CG. Does mHealth influence community health worker performance in vulnerable populations? A mixed methods study in a multinational refugee settlement in Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002741. [PMID: 38157328 PMCID: PMC10756529 DOI: 10.1371/journal.pgph.0002741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
Community Health Workers (CHWs) provide healthcare in under-served communities, including refugee settlements, despite various challenges hindering their performance. Implementers have adopted mobile wireless technologies (m-Health) to improve the performance of CHWs in refugee settlements. We assessed the CHWs' performance and associated factors in a multi-national refugee settlement, operating mHealth and paper-based methods. This cross-sectional study employed quantitative and qualitative data collection methods. Data for 300 CHWs was collected from implementing partners' (IPs) databases. Nine focus group discussions (FGDs) with the CHWs and community members, two in-depth interviews (IDIs) with CHW leaders, and eight key informant interviews (KIIs) with six IPs and two local leaders were conducted. The qualitative data were analysed thematically using AtlasTi version 9 while the quantitative data were analysed at the univariate, bivariate and multivariable levels using Stata version14. The study found that only 17% of the CHWs performed optimally. The factors that significantly influenced CHW performance included education level: secondary and above (APR: 1.83, 95% CI: 1.02-3.30), having a side occupation (APR: 2.02, 95% CI: 1.16-3.52) and mHealth use (APR: 0.06, 95% CI: 0.02-.0.30). The qualitative data suggested that performance was influenced by the number of households assigned to CHWs, monetary incentives, adequacy of materials and facilitation. Particularly, mHealth was preferred to paper-based methods. Overall, the CHWs' performance was sub-optimal; only 2 in 10 performed satisfactorily. The main factors that influenced performance included the level of education, use of mHealth, having another occupation, workload and incentivisation. CHWs and IPs preferred mHealth to paper-based methods. IPs should work to improve refugee settlement working conditions for the CHWs and adopt mHealth to improve CHW performance.
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Affiliation(s)
- Michael T. Wagaba
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Arthur Bagonza
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John B. Ddamulira
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Christine K. Nalwadda
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Christopher G. Orach
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Namukose S, Kiwanuka SN, Makumbi FE, Maina GW. Extent of integration of nutrition assessment counselling and support interventions in the health system and respective drivers: A case of Tororo district, Uganda. PLoS One 2023; 18:e0289389. [PMID: 38128006 PMCID: PMC10735038 DOI: 10.1371/journal.pone.0289389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Uganda embraced Nutrition Assessment Counselling and Support (NACS) since 2009 as a health system strengthening approach to improve health and nutrition outcomes. However, scant evidence exists on NACS integration and drivers. This study therefore assessed the extent of NACS integration in the health system and identified key drivers and barriers. METHODS A mixed method design was employed. In a facilitated panel discussions at each of the 17 health facilities, 4-5 health staff participated, responding to a semi-structured questionnaire. Integration was assessed on a 5-point scoring scale of 1 for not done nor integrated, 2-4 for partial and 5 for fully integration. Data was captured, analysed in microsoft excel and presented using as bar and spider charts. Integration drivers were identified deductively from key informant and in-depth interviews using Atlas.ti 9 and thematic analysis. RESULTS The NACS integration across the health facility level was partial at a score of 2.9 indicating a weak integration into the health system. Integration across the health system building blocks was partial at; service delivery (3.8), health work force (3.7), health information (3.3), community support system (3.0), governance and leadership (3.0) signifying that NACS activities are provided by Ministry of Health but sub-optimal due to weak capacities. Health financing (2.2) and Health supplies (1.5) were the least integrated due to partner dependence. Under service delivery, deworming (5) was fully integrated and provided by Ministry of Health. The key drivers for integration were; good leadership, financing, competent staff, quality improvement approaches, nutrition talks, community dialogues, nutrition logistics and supplies. CONCLUSION The NACS integration in the health system was generally low and lacked adequate support. Governance, financing and community follow-up under service delivery require more government investment for enhanced integration.
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Affiliation(s)
- Samalie Namukose
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Suzanne N. Kiwanuka
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fredrick Edward Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gakenia Wamuyu Maina
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Morales DR, Minchin M, Kontopantelis E, Roland M, Sutton M, Guthrie B. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ 2023; 380:e072098. [PMID: 36948515 PMCID: PMC10031759 DOI: 10.1136/bmj-2022-072098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVE To determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued. DESIGN Controlled interrupted time series regression analysis. SETTING General practices in Scotland and England. PARTICIPANTS 979 practices with 5 599 171 registered patients in Scotland, and 7921 practices with 56 270 628 registered patients in England in 2013-14, decreasing to 864 practices in Scotland and 6873 in England in 2018-19, mainly due to practice mergers. MAIN OUTCOME MEASURES Changes in quality of care at one year and three years after withdrawal of QOF financial incentives in Scotland at the end of the 2015-16 financial year for 16 indicators (two complex processes, nine intermediate outcomes, and five treatments) measured annually for financial years from 2013-14 to 2018-19. RESULTS A significant decrease in performance was observed for 12 of the 16 quality of care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished, compared with England. At three years, the absolute percentage point difference between Scotland and England was largest for recording (by tick box) of mental health care planning (-40.2 percentage points, 95% confidence interval -45.5 to -35.0) and diabetic foot screening (-22.8, -33.9 to -11.7). Substantial reductions were, however, also observed for intermediate outcomes, including blood pressure control in patients with peripheral arterial disease (-18.5, -22.1 to -14.9), stroke or transient ischaemic attack (-16.6, -20.6 to -12.7), hypertension (-13.7, -19.4 to -7.9), diabetes (-12.7, -15.0 to -12.4), or coronary heart disease (-12.8, -14.9 to -10.8), and for glycated haemoglobin control in people with HbA1c levels ≤75 mmol/mol (-5.0, -8.4 to -1.5). No significant differences were observed between Scotland and England for influenza immunisation and antiplatelet or anticoagulant treatment for coronary heart disease three years after withdrawal of incentives. CONCLUSION The abolition of financial incentives in Scotland was associated with reductions in recorded quality of care for most performance indicators. Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.
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Affiliation(s)
- Daniel R Morales
- Division of Population Health and Genomics, University of Dundee, UK
| | - Mark Minchin
- National Institute for Health and Care Excellence, Centre for Guidelines, Manchester, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
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Sakeah E, Bawah AA, Kuwolamo I, Anyorikeya M, Asuming PO, Aborigo RA. How different incentives influence reported motivation and perceptions of performance in Ghanaian community-based health planning and services zones. BMC Res Notes 2023; 16:17. [PMID: 36803880 PMCID: PMC9942281 DOI: 10.1186/s13104-023-06286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Maternal mortality is still a burden worldwide, and Ghana's maternal and child mortalities are still high. Incentive schemes have been effective in improving health workers' performance thereby reducing maternal and child deaths. The efficiency of public health services in most developing countries has been linked to the provision of incentives. Thus, financial packages for Community Health Volunteers (CHVs) serve as enablers for them to be focused and committed to their work. However, the poor performance of CHVs is still a challenge in health service delivery in many developing countries. Although the reasons for these persistent problems are understood, we need to find out how to implement what works in the face of political will and financial constraints. This study assesses how different incentives influence reported motivation and perceptions of performance in Community-based Health Planning and Services Program (CHPS) zones in the Upper East region. METHODS A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. The different interventions were rolled out in 55 of 120 CHPS zones. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive was a small monthly performance-based Stipend. The non-financial incentives were: Community recognition; paying for National Health Insurance Scheme (NHIS) premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based Awards for best-performing CHVs. The four groups represent the four different incentive schemes. We conducted 31 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members. RESULTS Community members and the CHVs wanted the stipend as the first incentive but requested that it be increased from the current level. The Community Health Officers (CHOs) prioritized the Awards over the Stipend because they felt it was too small to generate the required motivation in the CHVs. The second incentive was the National Health Insurance Scheme (NHIS) registration. Community recognition was also considered by health professionals as effective in motiving CHVs and work support inputs and CHVs training helped in improving output. The various incentives have helped increase health education and facilitated the work of the volunteers leading to increased outputs: Household visits and Antenatal Care and Postnatal Care coverage improved. The incentives have also influenced the initiative of volunteers. Work support inputs were also regarded as motivators by CHVs, but the challenges with the incentives included the size of the stipend and delays in disbursement. CONCLUSION Incentives are effective in motivating CHVs to improve their performance, thereby improving access to and use of health services by community members. The Stipend, NHIS, Community recognition and Awards, and the work support inputs all appeared to be effective in improving CHVs' performance and outcomes. Therefore, if health professionals implement these financial and non-financial incentives, it could bring a positive impact on health service delivery and use. Also, building the capacities of CHVs and providing them with the necessary inputs could improve output.
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Affiliation(s)
- Evelyn Sakeah
- School of Public Health, C.K. Tedam University of Technology and Applied Sciences, Navrongo, Ghana. .,Population/Public Health Department, Navrongo Health Research Centre, Navrongo, Ghana.
| | - Ayaga A. Bawah
- grid.8652.90000 0004 1937 1485Regional Institute for Population Studies, University of Ghana, Legon, Accra Ghana
| | - Irene Kuwolamo
- grid.415943.ePopulation/Public Health Department, Navrongo Health Research Centre, Navrongo, Ghana
| | - Maria Anyorikeya
- grid.415943.ePopulation/Public Health Department, Navrongo Health Research Centre, Navrongo, Ghana
| | - Patrick O. Asuming
- grid.8652.90000 0004 1937 1485Business School, University of Ghana, Legon, Accra Ghana
| | - Raymond Akawire Aborigo
- grid.415943.ePopulation/Public Health Department, Navrongo Health Research Centre, Navrongo, Ghana
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Impact and Sustainability of Foreign Medical Aid: A Qualitative Study with Honduran Healthcare Providers. Ann Glob Health 2023; 89:17. [PMID: 36876301 PMCID: PMC9983504 DOI: 10.5334/aogh.3995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
Background There is growing concern about the sustainability and long-term impact of short-term medical missions (STMMs)-an increasingly common form of foreign medical aid-given that brief engagements do little to address the underlying poverty and fragmented healthcare system that plagues many low- and middle-income countries (LMICs). In the absence of formal evaluations, unintended but serious consequences for patients and local communities may arise, including a lack of continuity of patient care, poor alignment with community needs, and cultural and language barriers. Objective We conducted semi-structured interviews with Honduran healthcare providers (n = 88) in 2015 to explore local providers' perceptions of the impact and sustainability of foreign medical aid on patient needs, community health, and the country's healthcare system. Methods Respondents represented a random sample of Honduran healthcare providers (physicians, dentists, nurses) who worked for either a government-run rural clinic or non-governmental organization (NGO) in Honduras. Findings Honduran healthcare providers largely framed foreign medical teams as being assets that help to advance community health through the provision of medical personnel and supplies. Nonetheless, most respondents identified strategies to improve implementation of STMMs and reduce negative impacts. Many respondents emphasized a need for culturally- and linguistically-tailored medical care and health education interventions. Participants also recommended strengthening local partnerships to mitigate the risk of dependence, including on-going training and support of community health workers to promote sustainable change. Conclusions Guidelines informed by local Honduran expertise are needed to increase accountability for more robust training of foreign physicians in the provision of context-appropriate care. These findings provide valuable local perspectives from Honduran healthcare providers to improve the development and implementation of STMMs, informing strategies that can complement and strengthen healthcare systems in LMICs.
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Sheikh N, Tagoe ET, Akram R, Ali N, Howick S, Morton A. Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders. BMC Health Serv Res 2022; 22:1200. [PMID: 36153512 PMCID: PMC9508716 DOI: 10.1186/s12913-022-08561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.
Methods
This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.
Results
The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.
Conclusions
Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.
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Moucheraud C, Epstein A, Sarma H, Kim SS, Nguyen PH, Rahman M, Tariquijaman M, Glenn J, Payán DD, Menon P, Bossert TJ. Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh. FRONTIERS IN HEALTH SERVICES 2022; 2:1005986. [PMID: 36925817 PMCID: PMC10012630 DOI: 10.3389/frhs.2022.1005986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023]
Abstract
Introduction Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion. Methods We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline). Results At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline. Discussion Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness-and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.
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Affiliation(s)
- Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
| | - Adrienne Epstein
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Haribondhu Sarma
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Sunny S Kim
- International Food Policy Research Institute, Washington, DC, United States
| | - Phuong Hong Nguyen
- International Food Policy Research Institute, Washington, DC, United States
| | - Mahfuzur Rahman
- International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Bangladesh
| | - Md Tariquijaman
- International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Bangladesh
| | - Jeffrey Glenn
- Department of Public Health, Brigham Young University, Provo, UT, United States
| | - Denise D Payán
- Department of Health, Society, and Behavior, University of California, Irvine, CA, United States
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Thomas J Bossert
- School of Public Health, Harvard University, Boston, MA, United States
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