1
|
Yuspahruddin A, Abbas H, Pahala I, Eliyana A, Yazid Z. Fostering proactive work behavior: Where to start? PLoS One 2024; 19:e0298936. [PMID: 38696381 PMCID: PMC11065301 DOI: 10.1371/journal.pone.0298936] [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: 01/16/2023] [Accepted: 02/01/2024] [Indexed: 05/04/2024] Open
Abstract
This study underscores the significance of assessing the capabilities of rehabilitation officers in navigating challenges, devising innovative work methods, and successfully executing the rehabilitation process. This is particularly crucial amid the dual challenges of overcapacity and the repercussions of the Covid-19 pandemic, making it an essential area for research. To be specific, it aims to obtain empirical evidence about the influence of proactive personality and supportive supervision on proactive work behavior, as well as the mediating role of Role Breadth Self-efficacy and Change Orientation. This research was conducted on all rehabilitation officers at the Narcotics Penitentiary in Sumatra, totaling 272 respondents. This study employs a quantitative method via a questionnaire using a purposive sampling technique. The data was subsequently examined using the Lisrel 8.70 software and Structural Equation Modeling (SEM). It can be concluded from the results that the rehabilitation officers for narcotics addicts at the Narcotics Penitentiary can create and improve proactive work behavior properly through the influence of proactive personality, supportive supervision, role breadth self-efficacy, and change orientation. The study may suggest new ways of working and generate new ideas to increase initiative, encourage feedback, and voice employee concerns. Furthermore, this research has the potential to pinpoint deficiencies in proactive work behavior, serving as a foundation for designing interventions or training programs. These initiatives aim to enhance the innovative and creative contributions of rehabilitation officers in the rehabilitation process.
Collapse
Affiliation(s)
- A. Yuspahruddin
- Postgraduate School, Universitas Negeri Jakarta, East Jakarta, DKI Jakarta, Indonesia
| | - Hafid Abbas
- Postgraduate School, Universitas Negeri Jakarta, East Jakarta, DKI Jakarta, Indonesia
| | - Indra Pahala
- Postgraduate School, Universitas Negeri Jakarta, East Jakarta, DKI Jakarta, Indonesia
| | - Anis Eliyana
- Department of Management, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Zaleha Yazid
- Faculty of Economics and Management, School of Management, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| |
Collapse
|
2
|
Islam MR, Angell B, Naher N, Islam BZ, Khan MH, McKee M, Hutchinson E, Balabanova D, Ahmed SM. Who is absent and why? Factors affecting doctor absenteeism in Bangladesh. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003040. [PMID: 38574057 PMCID: PMC10994372 DOI: 10.1371/journal.pgph.0003040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 02/27/2024] [Indexed: 04/06/2024]
Abstract
Absenteeism by doctors in public healthcare facilities in rural Bangladesh is a form of chronic rule-breaking and is recognised as a critical problem by the government. We explored the factors underlying this phenomenon from doctors' perspectives. We conducted a facility-based cross-sectional survey in four government hospitals in Dhaka, Bangladesh. Junior doctors with experience in rural postings were interviewed to collect data on socio-demographic characteristics, work and living experience at the rural facilities, and associations with professional and social networks. Multiple logistic regression was used to determine the factors associated with rural retention. Of 308 respondents, 74% reported having served each term of their rural postings without interruptions. The main reasons for absenteeism reported by those who interrupted rural postings were formal training opportunities (65%), family commitments (41%), and a miscellaneous group of others (17%). Almost half of the respondents reported unmanageable workloads. Most (96%) faced challenges in their last rural posting, such as physically unsafe environments (70%), verbally abusive behaviour by patients/caregivers (67%) and absenteeism by colleagues that impacted them (48%). Respondents who did not serve their entire rural posting were less likely to report an unmanageable workload than respondents who did (AOR 0.39, 95% CI 0.22-0.70). Respondents with connections to influential people in the local community had a 2.4 times higher chance of serving in rural facilities without interruption than others (AOR 2.40, 95% CI 1.26-4.57). Our findings demonstrate that absenteeism is not universal and depends upon doctors' socio-political networks. Policy interventions rarely target unsupportive or threatening behaviour by caregivers and community members, a pivotal disincentive to doctors' willingness to work in underserved rural areas. Policy responses must promote opportunities for doctors with weak networks who are willing to attend work with appropriate support.
Collapse
Affiliation(s)
- Mir Raihanul Islam
- Poverty, Gender and Inclusion Division, International Food Policy Research Institute, Dhaka, Bangladesh
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
| | - Nahitun Naher
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Bushra Zarin Islam
- School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Mushtaq Husain Khan
- School of Oriental and African Studies (SOAS), University of London, London, England
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eleanor Hutchinson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Syed Masud Ahmed
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| |
Collapse
|
3
|
Nida S, Tyas ASA, Putri NE, Larasanti A, Widoyopi AA, Sumayyah R, Listiana S, Espressivo A. A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia. BMC PRIMARY CARE 2024; 25:82. [PMID: 38468218 PMCID: PMC10926673 DOI: 10.1186/s12875-024-02319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries. METHODS The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs. RESULTS Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks. CONCLUSIONS Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.
Collapse
Affiliation(s)
- Sofwatun Nida
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia.
| | - Agatha Swasti Ayuning Tyas
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Nidya Eka Putri
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Ayudina Larasanti
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Aldhea Ayu Widoyopi
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Rima Sumayyah
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Saetia Listiana
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Aufia Espressivo
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| |
Collapse
|
4
|
Joubert A, Reid M. Knowledge, skills, and training of community health workers to contribute to interprofessional education: a scoping review. J Interprof Care 2024; 38:308-318. [PMID: 36821383 DOI: 10.1080/13561820.2023.2176472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 10/12/2022] [Accepted: 01/23/2023] [Indexed: 02/24/2023]
Abstract
A scoping review of 32 publications was conducted with the aim of mapping literature to determine what is known about the knowledge, skills, and training of community health workers that could contribute to interprofessional education. Interprofessional education, as a pedagogical approach, prepares health professions students to serve patients in collaboration with other health professionals to improve patient outcomes. All over the world, the role of community health workers is vital for its support of community service and community health outcomes. However, no evidence could be found on the knowledge, skills, and training of community health workers that contribute to interprofessional education. The knowledge that community health workers need to contribute to interprofessional education, as reported by the literature, relates to case management, communication, health education, recordkeeping and referrals. Skills, such as critical thinking, interprofessional collaboration, and various clinical procedures, were noted. Training approaches reported included the use of technology such as mobile phones and web-based learning. The scoping review improved our understanding of the knowledge, skills, and training of community health workers that could contribute to interprofessional education. Applying a fit-for-purpose approach, and building on existing knowledge, skills, and training, could fast-track the contribution of community health workers to interprofessional education.
Collapse
Affiliation(s)
- Annemarie Joubert
- School of Nursing, University of the Free State, Bloemfontein, South Africa
| | - Marianne Reid
- School of Nursing, University of the Free State, Bloemfontein, South Africa
| |
Collapse
|
5
|
Matsi MM, Lekalakala-Mokgele ES, Madumo MM. Community health workers' experiences of supervision by nurses at clinics in Limpopo Province. Health SA 2023; 28:2330. [PMID: 38204862 PMCID: PMC10778378 DOI: 10.4102/hsag.v28i0.2330] [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: 01/28/2023] [Accepted: 09/06/2023] [Indexed: 01/12/2024] Open
Abstract
Background Supervision of community health workers (CHWs) is considered, among others, a strategy to achieve universal healthcare globally. In South Africa, it is incorporated in the ward-based primary healthcare (PHC) outreach teams' policy and strategy, a national health insurance policy component. Supervision of CHWs by nurses in the policy is considered a measure to facilitate PHC service provision to communities. However, CHWs experienced varying levels of supervision from nurses and other workers globally and in South Africa. Aim This study explored and described the experiences of CHWs about supervision received from nurses at PHC facilities in Limpopo Province. Setting Participants were drawn from seven PHC facilities in Polokwane and Lepelle-Nkumpi subdistricts of the Capricorn District. Methods A qualitative exploratory-descriptive and contextual study design was employed. Participants were selected utilising a purposive sampling method. Semi-structured interviews were conducted to collect data. Data were analysed according to themes and their associated categories. Measures to ensure rigour and ethical principles were applied. Results Two main themes emerged: positive supervision experienced by CHWs and supervision challenges experienced by CHWs. Conclusion The varying experiences of CHWs about supervision from nurses emerged and reflected the need for functioning supervision mechanisms. Contribution The experiences of CHWs indicated inconsistent delivery of supervision by nurses in PHC facilities. The findings highlighted the need for effective supervision measures that are vital for the success of the CHW supervision programme.
Collapse
Affiliation(s)
- Makwena M Matsi
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Eucebious S Lekalakala-Mokgele
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mary M Madumo
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
6
|
Wagner J, Barth C, Bermúdez-Millán A, Buxton OM, Kong S, Kuoch T, Lampert R, Pérez-Escamilla R, Scully M, Segura-Pérez S. Lay health worker research personnel for home-based data collection in clinical and translational research: Qualitative and quantitative findings from two trials in hard-to-reach populations. J Clin Transl Sci 2023; 7:e228. [PMID: 38028343 PMCID: PMC10643917 DOI: 10.1017/cts.2023.647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/16/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023] Open
Abstract
Aims The role of lay health workers in data collection for clinical and translational research studies is not well described. We explored lay health workers as data collectors in clinical and translational research studies. We also present several methods for examining their work, i.e., qualitative interviews, fidelity checklists, and rates of unusable/missing data. Methods We conducted 2 randomized, controlled trials that employed lay health research personnel (LHR) who were employed by community-based organizations. In one study, n = 3 Latina LHRs worked with n = 107 Latino diabetic participants. In another study, n = 6 LHR worked with n = 188 Cambodian American refugees with depression. We investigated proficiency in biological, behavioral, and psychosocial home-based data collection conducted by LHR. We also conducted in-depth interviews with lay LHR to explore their experience in this research role. Finally, we described the training, supervision, and collaboration for LHR to be successful in their research role. Results Independent observers reported a very high degree of fidelity to technical data collection protocols (>95%) and low rates of missing/unusable data (1.5%-11%). Qualitative results show that trust, training, communication, and supervision are key and that LHR report feeling empowered by their role. LHR training included various content areas over several weeks with special attention to LHR and participant safety. Training and supervision from both the academic researchers and the staff at the community-based organizations were necessary and had to be well-coordinated. Conclusions Carefully selected, trained, and supervised LHRs can collect sophisticated data for community-based clinical and translational research.
Collapse
Affiliation(s)
| | - Cheryl Barth
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Sengly Kong
- Khmer Health Advocates, West Hartford, CT, USA
| | | | | | | | - Mary Scully
- Khmer Health Advocates, West Hartford, CT, USA
| | | |
Collapse
|
7
|
Katzen LS, Skeen S, Dippenaar E, Laurenzi C, Notholi V, le Roux K, le Roux I, WaluWalu N, Mbewu N, Borus MJR, Tomlinson M. Community Health Workers' experiences of a package providing increased support and supervision - a qualitative study of a home visiting model in rural South Africa. RESEARCH SQUARE 2023:rs.3.rs-3333610. [PMID: 37841874 PMCID: PMC10571624 DOI: 10.21203/rs.3.rs-3333610/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Deploying Community Health Workers is a crucial strategy to improve health at a community level in low and middle income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW's experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using a qualitative study embedded within a cluster randomized controlled trial of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa. We interviewed CHWs (n = 16) and two supervisors. Three overarching areas and five sub-themes emerged from our interviews. CHW knowledge and confidence increased through additional training, that CHW motivation and community acceptance improved because of added logistical support, and that CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively.
Collapse
|
8
|
Gebremeskel AT, Udenigwe O, Etowa J, Yaya S. Unpacking the challenges of fragmentation in community-based maternal newborn and child health and health system in rural Ethiopia: A qualitative study. PLoS One 2023; 18:e0291696. [PMID: 37733782 PMCID: PMC10513239 DOI: 10.1371/journal.pone.0291696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION In Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program's significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia's maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia's Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system. METHODS We conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization's health systems framework and socio-ecological model guided the data collection, analysis, and interpretation. RESULTS The CHWs program has been an extended arm of Ethiopia's primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges. CONCLUSION This study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.
Collapse
Affiliation(s)
- Akalewold T. Gebremeskel
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- School of Nursing, Faculty of Health Sciences University of Ottawa, Ottawa, Ontario, Canada
| | - Ogochukwu Udenigwe
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
| | - Josephine Etowa
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- School of Nursing, Faculty of Health Sciences University of Ottawa, Ottawa, Ontario, Canada
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- The George Institute for Global Health, Imperial College London, London, United Kingdom
| |
Collapse
|
9
|
Kyomuhangi T, Manalili K, Kabakyenga J, Turyakira E, Matovelo D, Khan S, Kyokushaba C, MacIntosh H, Brenner JL. Health system strengthening using a Maximizing Engagement for Readiness and Impact (MERI) Approach: A community case study. Front Public Health 2022; 10:952213. [PMID: 36504976 PMCID: PMC9727261 DOI: 10.3389/fpubh.2022.952213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Health system strengthening initiatives in low and middle-income countries are commonly hampered by limited implementation readiness. The Maximizing Engagement for Readiness and Impact (MERI) Approach uses a system "readiness" theory of change to address implementation obstacles. MERI is documented based on field experiences, incorporating best practices, and lessons learned from two decades of maternal, newborn, and child health (MNCH) programming in East Africa. Context The MERI Approach is informed by four sequential and progressively larger MNCH interventions in Uganda and Tanzania. Intervention evaluations incorporating qualitative and quantitative data sources assessed health and process outcomes. Implementer, technical leader, stakeholder, and policymaker reflections on sequential experiences have enabled MERI Approach adaptation and documentation, using an implementation lens and an implementation science readiness theory of change. Key programmatic elements The MERI Approach comprises three core components. MERI Change Strategies (meetings, equipping, training, mentoring) describe key activity types that build general and intervention-specific capacity to maximize and sustain intervention effectiveness. The SOPETAR Process Model (Scan, Orient, Plan, Equip, Train, Act, Reflect) is a series of purposeful steps that, in sequence, drive each implementation level (district, health facility, community). A MERI Motivational Framework identifies foundational factors (self-reliance, collective-action, embeddedness, comprehensiveness, transparency) that motivate participants and enhance intervention adoption. Components aim to enhance implementer and system readiness while engaging broad stakeholders in capacity building activities toward health outcome goals. Activities align with government policy and programming and are embedded within existing district, health facility, and community structures. Discussion This case study demonstrates feasibility of the MERI Approach to support district wide MNCH programming in two low-income countries, supportive of health outcome and health system improvements. The MERI Approach has potential to engage districts, health facilities, and communities toward sustainable health outcomes, addressing intervention implementation gaps for current and emerging health needs within and beyond East Africa.
Collapse
Affiliation(s)
- Teddy Kyomuhangi
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda,*Correspondence: Teddy Kyomuhangi
| | - Kimberly Manalili
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda,Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Eleanor Turyakira
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda,Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dismas Matovelo
- Department of Obstetrics and Gynecology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Sobia Khan
- The Center for Implementation, Toronto, ON, Canada
| | - Clare Kyokushaba
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Heather MacIntosh
- Indigenous, Local and Global Health Office, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer L. Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada,Indigenous, Local and Global Health Office, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
10
|
Hämmerli P, Moukam AD, Wisniak A, Sormani J, Vassilakos P, Kenfack B, Petignat P, Schmidt NC. "My motivation was to save": a qualitative study exploring factors influencing motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. Reprod Health 2022; 19:133. [PMID: 35668427 PMCID: PMC9167909 DOI: 10.1186/s12978-022-01420-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cervical cancer is a major public health issue among women in Cameroon and uptake of screening programs remains a challenge in many low- and middle-income countries. Community healthcare workers can play an important role in promoting cervical cancer services. This study aimed to explore factors affecting the motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. Methods A qualitative approach including 11 in-depth individual interviews with community healthcare workers was used. The interviews were audio-recorded, transcribed and coded using thematic analysis assisted by ATLAS.ti software. Results Four women and seven men aged between 21 and 77 years old were interviewed. Community healthcare workers had high motivation. Factors affecting motivation were divided into individual and environmental level, based on a theoretical framework. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Conclusions Key interventions to improve motivation among community healthcare workers include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport. Trial registration: Geneva Cantonal Ethics Committee on Human Research (No. 2017-01110) and the Cameroonian National Ethics Committee for Human Health Research (No. 2018/07/1083/CE/CNERSH/SP). Cervical cancer is the second leading cause of cancer-related death among women in Cameroon. This is mainly due to the absence of routine cervical cancer screening programs and the lack of treatment. However, even in case of availability of cervical cancer screening programs, barriers exist. Therefore, community healthcare workers have been involved successfully to increase the screening coverage. As retention of these actors remains a challenge, the main objective of this study was to identify key factors affecting their motivation aiming to suggest interventions to address motivational factors. 11 qualitative interviews with individual community healthcare workers were conducted at a cervical cancer screening program in Dschang, Cameroon. Motivation was generally high and affecting factors were divided into the individual and the environmental level. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Ongoing collaboration with community healthcare workers is beneficial for cervical cancer screening programs, and key interventions should therefore include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.
Collapse
Affiliation(s)
| | - Alida Datchoua Moukam
- Department of Gynaecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Ania Wisniak
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Jessica Sormani
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.,Geneva School of Health Sciences, HESSO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Gynaecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Patrick Petignat
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Nicole Christine Schmidt
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland. .,Faculty of Social Science, Catholic University of Applied Science, Preysingstr. 95, 81667, Munich, Germany.
| |
Collapse
|
11
|
Stansert Katzen L, Skeen S, Dippenaar E, Laurenzi C, Notholi V, le Roux K, Rotheram-Borus MJ, le Roux I, Mbewu N, Tomlinson M. Are we listening to community health workers? Experiences of the community health worker journey in rural South Africa. Res Nurs Health 2022; 45:380-389. [PMID: 35184308 PMCID: PMC9271365 DOI: 10.1002/nur.22220] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/13/2021] [Accepted: 02/01/2022] [Indexed: 08/20/2023]
Abstract
Access to healthcare in developing countries remains a challenge. As a result, task-shifting to community health workers (CHWs) is increasingly used to mitigate healthcare worker shortages. Although there is solid evidence of CHW program effectiveness, less is known about CHWs' experiences of becoming and then working daily as CHWs-information that should play an important role in the design of CHW programs. We examined the experiences of a group of CHWs working in a government-run CHW program in South Africa's rural Eastern Cape Province. Semistructured qualitative interviews (N = 9) and focus groups (N = 2) focusing on motivations for becoming a CHW and experiences of working as CHWs were conducted and thematically analyzed. Three themes were identified: (1) becoming a CHW, (2) facing challenges in the field, and (3) gaining community acceptance through respect and legitimacy. In this study, CHWs were motivated by altruism and a desire to help their community. They faced a range of challenges such as limited training, lack of supervision, equipment shortages, logistical issues, and clinics with limited services. Respect and legitimacy through community acceptance and trust is crucial for effective CHW work. CHWs in this study described how confidentiality and their own persistence facilitated the process of gaining respect and legitimacy. CHWs have a unique knowledge of contexts and requirements for successful programs and greater efforts are needed to include their perspectives to improve and develop programs. Recognition is needed to acknowledge the significant personal input required by CHWs for programs to be successful.
Collapse
Affiliation(s)
- Linnea Stansert Katzen
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
| | - Sarah Skeen
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
| | - Elaine Dippenaar
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
| | - Christina Laurenzi
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
| | - Vuyolwethu Notholi
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
| | - Karl le Roux
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
- Department of Family Medicine, Walter Sisulu University, Mthatha, South Africa
| | - Mary Jane Rotheram-Borus
- Department of Psychiatry & Biobehavioral Sciences, Semel Institute, University of California, Los Angeles, California, USA
| | - Ingrid le Roux
- Philani Maternal, Child Health and Nutrition Trust, Cape Town, South Africa
| | - Nokwanele Mbewu
- Philani Maternal, Child Health and Nutrition Trust, Cape Town, South Africa
| | - Mark Tomlinson
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Cape Town, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, UK
| |
Collapse
|
12
|
Gebremeskel AT, Omonaiye O, Yaya S. Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review. BMJ Glob Health 2022; 7:bmjgh-2021-008162. [PMID: 35393287 PMCID: PMC8991040 DOI: 10.1136/bmjgh-2021-008162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/26/2022] [Indexed: 12/29/2022] Open
Abstract
Background Countries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile health systems. Community health workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in improving maternal and child health (MCH). However, evidence is limited on multilevel determinants of an effective CHWs programme using CHWs’ perspective. The objective of this systematic review is to examine perceived barriers to and enablers of different levels of the determinants of the CHWs’ engagement to enhance MCH equity and a resilient community health system in SSA. Methods We systematically conducted a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Qualitative studies that presented information on perceived barriers to and facilitators of effectiveness of CHWs in SSA were eligible for inclusion. Quality appraisal was conducted according to the Critical Appraisal Skills Programme qualitative study checklist. We used a framework analysis to identify key findings. Findings From the database search, 1561 articles were identified. Nine articles met the inclusion criteria and were included in the final review. Using socio-ecological framework, we identified the determinants of CHWs’ effectiveness at 4 levels: individual/CHWs, interpersonal, community and health system logistics. Under each level, we identified themes of perceived barriers such as competency gaps, lack of collaboration, fragmentation of empowerment programmes. In terms of facilitators, we identified themes such as CHW empowerment, interpersonal effectiveness, community trust, integration of CHWs into health systems and technology. Conclusion Evidence from this review revealed that effectiveness of CHW/MCH programme is determined by multilevel contextual factors. The socio-ecological framework can provide a lens of understanding diverse context that impedes or enhances CHWs’ engagement and effectiveness at different levels. Hence, there is a need for health programme policy makers and practitioners to adopt a multilevel CHW/MCH programme guided by the socio-ecological framework to transform CHW programmes. The framework can help to address the barriers and scale up the facilitators to ensuring MCH equity and a resilient community health system in SSA.
Collapse
Affiliation(s)
- Akalewold T Gebremeskel
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.,School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
| | - Olumuyiwa Omonaiye
- School of Health and Social Development, Institute for Health Transformation, Deakin University, Melbourne-Burwood Campus, Burwood, Victoria, Australia
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada .,The George Institute for Global Health, Imperial College London, London, UK
| |
Collapse
|
13
|
Malatji H, Griffiths F, Goudge J. Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa. BMC Health Serv Res 2022; 22:323. [PMID: 35272666 PMCID: PMC8908295 DOI: 10.1186/s12913-022-07635-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa. METHODS We conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives. RESULTS The nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs' activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities' focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures. CONCLUSIONS A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs' formal employment by the Department of Health.
Collapse
Affiliation(s)
- Hlologelo Malatji
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Frances Griffiths
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, Warwick University, Coventry, UK
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
14
|
Abujaber N, Vallières F, McBride KA, Sheaf G, Blum PT, Wiedemann N, Travers Á. Examining the evidence for best practice guidelines in supportive supervision of lay health care providers in humanitarian emergencies: A systematic scoping review. J Glob Health 2022; 12:04017. [PMID: 35265328 PMCID: PMC8876157 DOI: 10.7189/jogh.12.04017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nadeen Abujaber
- Trinity Centre for Global Health, School of Psychology, Trinity College Dublin, College Green, Dublin, Ireland
| | - Frédérique Vallières
- Trinity Centre for Global Health, School of Psychology, Trinity College Dublin, College Green, Dublin, Ireland
| | - Kelly A McBride
- International Federation of Red Cross and Red Crescent Societies, Copenhagen, Denmark
| | - Greg Sheaf
- Trinity Centre for Global Health, School of Psychology, Trinity College Dublin, College Green, Dublin, Ireland
| | - Pia Tingsted Blum
- International Federation of Red Cross and Red Crescent Societies, Copenhagen, Denmark
| | - Nana Wiedemann
- International Federation of Red Cross and Red Crescent Societies, Copenhagen, Denmark
| | - Áine Travers
- Trinity Centre for Global Health, School of Psychology, Trinity College Dublin, College Green, Dublin, Ireland
| |
Collapse
|
15
|
Kpienbaareh D, Kofinti RE, Konkor I, Amoak D, Kansanga MM, Luginaah I. Knowledge of pregnancy complications and utilization of antenatal care services in Rwanda. Int J Health Plann Manage 2022; 37:1680-1693. [PMID: 35150019 DOI: 10.1002/hpm.3434] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/30/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND While Rwanda's progress towards achieving the maternal health care targets of the Sustainable Development Goals is impressive, evidence of women's limited utilization of antenatal care (ANC) services in the context of an improved health care system provides an opportunity for exploring other essential but less highlighted factors that may shape ANC service utilization. In this study, we examined the association between women's knowledge of pregnancy complications and the utilization of maternal health services. METHODS We employed logistic regression analysis using the 2015 Rwanda Demographic and Health Survey data. Our analytical sample consisted of women (n = 5883) in their reproductive ages (15-49 years). Three maternal health care indicators, namely, timing of first ANC visit, number of ANC visits, and place of delivery, were explored. We controlled for the effects of socioeconomic and demographic characteristics, including marital status, place of residence and age. RESULTS The results show that women with no knowledge of pregnancy complications were less likely to utilize ANC services within the first trimester (odds ratio [OR] = 0.76, p < 0.01), achieve the WHO recommended minimum of eight visits (OR = 0.66, p < 0.01), and deliver at a health facility (OR = 0.77, p < 0.10). CONCLUSION Given these findings, we recommend restructuring existing maternal health care programs to include rigorous maternal health education.
Collapse
Affiliation(s)
- Daniel Kpienbaareh
- Department of Geography and Environment, University of Western Ontario, London, Ontario, Canada
| | | | - Irenius Konkor
- Department of Geography, Geomatics and Environment, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Daniel Amoak
- Department of Geography and Environment, University of Western Ontario, London, Ontario, Canada
| | | | - Isaac Luginaah
- Department of Geography and Environment, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
16
|
Deussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. Systematic review of performance-enhancing health worker supervision approaches in low- and middle-income countries. HUMAN RESOURCES FOR HEALTH 2022; 20:2. [PMID: 34991604 PMCID: PMC8733429 DOI: 10.1186/s12960-021-00692-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rachel Deussom
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Doris Mwarey
- Human Resources for Health Consultant, Formerly With Chemonics International, PO Box 26432–00100, Nairobi, Kenya
| | - Mekdelawit Bayu
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Sarah S. Abdullah
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Rachel Marcus
- Office of Health Systems, Bureau for Global Health, United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20004 United States of America
| |
Collapse
|
17
|
Hobbs AJ, Manalili K, Turyakira E, Kabakyenga J, Kyomuhangi T, Nettel-Aguirre A, Kyokushaba C, Rwandekeye P, Brenner JL. Five-year Retention of Volunteer Community Health Workers in Rural Uganda: A Population-Based Retrospective Cohort. Health Policy Plan 2021; 37:483-491. [PMID: 34922343 PMCID: PMC9006062 DOI: 10.1093/heapol/czab151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/30/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022] Open
Abstract
Community health workers (CHWs) effectively improve maternal, newborn and child health (MNCH) outcomes in low-to-middle-income countries. However, CHW retention remains a challenge. This retrospective registry analysis evaluated medium-term retention of volunteer CHWs in two rural Ugandan districts, trained during a district-wide MNCH initiative. From 2012 to 2014, the Healthy Child Uganda partnership facilitated district-led CHW programme scale-up. CHW retention was tracked prospectively from the start of the intervention up to 2 years. Additional follow-up occurred at 5 years to confirm retention status. Database analysis assessed CHW demographic characteristics, retention rates and exit reasons 5 years post-intervention. A multivariable logistic regression model examined 5-year retention-associated characteristics. Of the original cohort of 2317 CHWs, 70% were female. The mean age was 38.8 years (standard deviation, SD: 10.0). Sixty months (5 years) after the start of the intervention, 84% of CHWs remained active. Of those exiting (n = 377), 63% reported a ‘logistical’ reason, such as relocation (n = 96), new job (n = 51) or death (n = 30). Sex [male, female; odds ratio (OR) = 1.53; 95% confidence interval (CI): 1 · 20–1 · 96] and age group (<25 years, 30–59; OR = 0.40; 95% CI: 0.25–0.62) were significantly associated with 5-year retention in multivariable modelling. Education completion (secondary school, primary) was not significantly associated with retention in adjusted analyses. CHWs in this relatively large cohort, trained and supervised within a national CHW programme and district-wide MNCH initiative, were retained over the medium term. Importantly, high 5-year retention in this intervention counters findings from other studies suggesting low retention in government-led and volunteer CHW programmes. Encouragingly, findings from our study suggest that retention was high, not significantly associated with timing of external partner support and largely not attributed to the CHW role i.e. workload and programme factors. Our study showcases the potential for sustainable volunteer CHW programming at scale and can inform planners and policymakers considering programme design, including selection and replacement planning for CHW networks.
Collapse
Affiliation(s)
- Amy J Hobbs
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, TRW Building 3rd Floor, 3280 Hospital Drive NW., Calgary, Alberta, T2N 4Z6, Canada
| | - Kimberly Manalili
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, TRW Building 3rd Floor, 3280 Hospital Drive NW., Calgary, Alberta, T2N 4Z6, Canada
| | - Eleanor Turyakira
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, P.O. BOX 1410, Mbarara, Uganda
| | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, P.O. BOX 1410, Mbarara, Uganda
| | - Teddy Kyomuhangi
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, P.O. BOX 1410, Mbarara, Uganda
| | - Alberto Nettel-Aguirre
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, TRW Building 3rd Floor, 3280 Hospital Drive NW., Calgary, Alberta, T2N 4Z6, Canada.,Centre for Health and Social Analytics, National Institute for Applied Statistics Research Australia, SMAS, University of Wollongong, Wollongong, NSW, 2520 Australia
| | - Clare Kyokushaba
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, P.O. BOX 1410, Mbarara, Uganda
| | - Polar Rwandekeye
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, P.O. BOX 1410, Mbarara, Uganda
| | - Jennifer L Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, TRW Building 3rd Floor, 3280 Hospital Drive NW., Calgary, Alberta, T2N 4Z6, Canada.,Department of Paediatrics, Cumming School of Medicine, University of Calgary, 28 Oki Drive NW., Calgary, Alberta, T3B 6A8, Canada
| |
Collapse
|
18
|
Rabbani F, Khan HA, Piryani S, Pradhan NA, Shaukat N, Feroz AS, Perveen S. Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan. J Multidiscip Healthc 2021; 14:3343-3355. [PMID: 34880624 PMCID: PMC8648085 DOI: 10.2147/jmdh.s334844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Diarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan’s rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia. Study Setting and Design This perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis. Results The perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs’ trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs. Conclusion Despite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers’ ability to manage such cases is also enhanced.
Collapse
Affiliation(s)
- Fauziah Rabbani
- Office of Research and Graduate Studies, The Aga Khan University, Karachi, Sindh, Pakistan.,Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Hyder Ali Khan
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Suneel Piryani
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Nousheen Akber Pradhan
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Natasha Shaukat
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Anam Shahil Feroz
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Shagufta Perveen
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| |
Collapse
|
19
|
Gopalakrishnan L, Diamond-Smith N, Avula R, Menon P, Fernald L, Walker D, Patil S. Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis. HUMAN RESOURCES FOR HEALTH 2021; 19:145. [PMID: 34838060 PMCID: PMC8627081 DOI: 10.1186/s12960-021-00689-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/13/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. OBJECTIVES We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. METHODS We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. RESULTS Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. CONCLUSION Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. TRIAL REGISTRATION Trial registration number: https://doi.org/10.1186/ISRCTN83902145.
Collapse
Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Lia Fernald
- University of California Berkeley, Berkeley, USA
| | - Dilys Walker
- University of California San Francisco, San Francisco, USA
| | - Sumeet Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| |
Collapse
|
20
|
LeBan K, Kok M, Perry HB. Community health workers at the dawn of a new era: 9. CHWs' relationships with the health system and communities. Health Res Policy Syst 2021; 19:116. [PMID: 34641902 PMCID: PMC8506091 DOI: 10.1186/s12961-021-00756-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This is the ninth paper in our series, "Community Health Workers at the Dawn of a New Era". Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities. METHODS The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes. RESULTS The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders. CONCLUSION To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.
Collapse
Affiliation(s)
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Henry B Perry
- Department of International Health, Health Systems Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
21
|
Westgate C, Musoke D, Crigler L, Perry HB. Community health workers at the dawn of a new era: 7. Recent advances in supervision. Health Res Policy Syst 2021; 19:114. [PMID: 34641909 PMCID: PMC8507092 DOI: 10.1186/s12961-021-00754-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Supervision is essential for optimizing performance and motivation of community health workers (CHWs). This paper, the seventh in our series, "Community health workers at the dawn of a new era", supplements the existing evidence on CHW supervision in low- and middle-income countries by reviewing what supervision approaches are employed in specific contexts, identifying potential facilitators of CHW supervision including mobile health (mHealth) interventions, and noting challenges of supervision including the relationship between supervision and other CHW programme elements. METHODS For this exploratory research study on CHW supervision, we reviewed the supervisory interventions described in a compendium of 29 case studies of large-scale CHW programmes, performed an electronic search of multiple databases to identify articles related to CHW supervision published between 15 June 2017 and 1 December 2020, and from those articles followed additional references that appeared to be relevant for our results. RESULTS We reviewed 55 case studies, academic articles, and grey literature resources as part of this exploratory research. A variety of supervision approaches have been adapted over time, which we grouped into five categories: external supervision, community supervision, group supervision, peer supervision, and dedicated supervision. These approaches are frequently used in combination. Digital (mHealth) technologies are being explored as potential facilitators of CHW supervision in both small- and large-scale programmes; however, evidence of their effectiveness remains limited to date. Inadequate support for supervisors is a major challenge, particularly given the numerous and varied roles they are expected to fulfil, spanning administrative, clinical, and supportive activities. Supervisors can help CHWs acquire other critical elements needed from the health system for them to perform more effectively: incentives to foster motivation, clarity of roles and tasks, adequate tools and supplies, appropriate knowledge and skills, and a safe work environment. CONCLUSION In the absence of a universal "best approach" for CHW supervision, our recommendation is that countries and programmes prioritize homegrown evolution over time to suit the local context. In some cases, this may involve scaling up novel approaches that have proven effective at small scale or testing approaches that have worked in other countries.
Collapse
Affiliation(s)
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Henry B Perry
- Department of International Health, Health Systems Program, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| |
Collapse
|
22
|
Ludwick T, Endrias M, Morgan A, Kane S, McPake B. Moving From Community-Based to Health-Centre Based Management: Impact on Urban Community Health Worker Performance in Ethiopia. Health Policy Plan 2021; 37:169-188. [PMID: 34519336 DOI: 10.1093/heapol/czab112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
Abstract
Community health worker (CHW) performance is influenced by the way in which management arrangements are configured vis-a-vis the community and health services. While low/middle-income contexts are changing, the literature provides few examples of country efforts to strategically modify management arrangements to support evolving CHW roles (e.g. chronic disease care) and operating environments (e.g. urbanization). This paper aims to understand the performance implications of changing from community-based to health centre-based management, on Ethiopia's Urban Health Extension Professionals (UHEPs), and the tensions/trade-offs associated with the respective arrangements. We conducted semi-structured interviews/focus groups to gather perspectives and preferences from those involved with the transition (13 managers/administrators, 5 facility-based health workers, 20 UHEPs). Using qualitative content analysis, we deductively coded data to four program elements impacted by changed management arrangements and known to affect CHW performance (work scope; community legitimacy; supervision/oversight/ownership; facility linkages) and inductively identified tensions/trade-offs. Community-based management was associated with wider work scope, stronger ownership/regular monitoring, weak technical support, and weak health center linkages, with opposite patterns observed for health center-led management. Practical trade-offs included: heavy UHEP involvement in political/administrative activities under Kebele-based management; resistance to working with UHEPs by facility-based workers; and, health centre capacity constraints in managing UHEPs. Whereas the Ministry of Health/UHEPs favoured health centre-led management to capitalize on UHEPs' technical skills, Kebele officials were vested in managing UHEPs and argued for community interests over UHEPs' professional interests; health facility managers/administrators held divided opinions. Management arrangements influence the nature of CHW contributions towards the achievement of health, development, and political goals. Decisions about appropriate management arrangements should align with the nature of CHW roles and consider implementation setting, including urbanization, political decentralization, and relative capacity of managing institutions.
Collapse
Affiliation(s)
- Teralynn Ludwick
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, 333 Exhibition Street, Carlton, Victoria, Australia
| | - Misganu Endrias
- Health Research and Technology Transfer Office, SNNPR Regional Health Bureau, Hawassa, Ethiopia
| | - Alison Morgan
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Global Financing Facility, The World Bank Group, Washington, DC, USA
| | - Sumit Kane
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Barbara McPake
- Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| |
Collapse
|
23
|
O'Donovan J, Saul Namanda A, Hamala R. Exploring supervision for volunteer community health workers in Mukono District, Uganda: An exploratory mixed-methods study. Glob Public Health 2021; 17:1958-1972. [PMID: 34459360 DOI: 10.1080/17441692.2021.1969671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Community Health Worker (CHW) supervision is an under-researched area. This mixed-methods study engaged key stakeholders involved in CHW supervision in Mukono District, Uganda including CHWs (n = 14), District Health Office officials (n = 5), NGO programme managers (n = 3) and facility-based health staff (n = 3). Our study aimed to explore how supervision is currently conceptualised and delivered in this setting, the desired qualities of a potential supervisor, as well as the challenges regarding supervision and potential solutions to address these. To understand these concepts, we conducted structured surveys and individual interviews. Survey data were analysed in SPSS using descriptive statistics. Interview transcripts were thematically analysed in NVivo using conventional content analysis. This study revealed current CHW supervision in this context is fragmented. Supervision is perceived both as a means of motivating CHWs and facilitating ongoing training, as well as a way of holding CHWs accountable for their work. Stakeholders identified technical knowledge and expertise, strong interpersonal skills and cultural awareness as desirable qualities for a supervisor. Challenges surrounding supervision included a shortage of funding, a lack of guidelines on supervision, and infrequent supervision. To address these challenges, stakeholders proposed the need for increased funding, creating clearer job descriptions for supervisors, and in-person supervisory meetings.
Collapse
Affiliation(s)
- James O'Donovan
- Learning and New Technologies Research Group, Department of Education, University of Oxford, Oxford, UK.,Division of Research and Health Equity, Omni Med, Mukono, Uganda
| | | | - Rebecca Hamala
- Division of Research and Health Equity, Omni Med, Mukono, Uganda
| |
Collapse
|
24
|
Bellerose M, Alva S, Magalona S, Awoonor-Williams K, Sacks E. Supervision of community health nurses in Ghana: a mixed-methods study on experiences and mentorship needs. Health Policy Plan 2021; 36:720-727. [PMID: 33351910 DOI: 10.1093/heapol/czaa167] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/23/2022] Open
Abstract
Adequate supervision is critical to maintain the performance of health workers who provide essential maternal and child health services in low-resource areas. Supportive supervision emphasizing problem-solving, skill development and mentorship has been shown to improve the motivation and effectiveness of health workers, especially at the community level, but it is not always routinely provided. Previous studies have assessed the uptake of supportive supervision among volunteer health workers and paid health centre staff, but less is known about the supervision experiences of paid community-based staff, such as community health nurses (CHNs) in Ghana. This mixed-methods study explores the frequency and content of CHN supervision in five districts in the Greater Accra and Volta regions of Ghana. We analysed quantitative data from 197 satisfaction surveys and qualitative data from 29 in-depth interviews (IDIs) and four focus group discussions (FGDs) with CHNs. While the majority of CHNs received supervision at least monthly, they reported that supervision was primarily focused on meeting clinical targets (48%) rather than on handling specific cases or patients (23%). Over a third (34%) of CHNs did not agree that supervisors help them with job-related challenges and nearly half (43%) were unsatisfied with their jobs. When asked about their mentorship needs, CHNs reported wanting feedback on how to improve their job performance (40%) and encouragement (30%). There were only slight variations in the frequency and content of supervision based on type of supervisor. During IDIs and FGDs, CHNs offered ideas for how to improve supervision, including more frequent field visits so that supervisors could see the on-the-ground realities of their work, greater respect and positive reinforcement. Overall, CHN motivation and job satisfaction may be strengthened by aligning supervision more closely with the principles of supportive supervision.
Collapse
Affiliation(s)
- Meghan Bellerose
- Department of Population and Family Health, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY 10032, USA
| | - Soumya Alva
- John Snow Inc, 2733 Crystal Dr 4th floor, Arlington, VA 22202, USA
| | - Sophia Magalona
- Department of Population, Family, and Reproductive Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Koku Awoonor-Williams
- Division of Policy Planning Monitoring and Evaluation, Ghana Health Service, Accra, Ghana
| | - Emma Sacks
- Department of International Health, Johns Hopkins School of Public Health, North Wolfe Street, E8011, Baltimore, MD 21205, USA
| |
Collapse
|
25
|
Nyamhanga TM, Frumence G, Hurtig AK. Facilitators and barriers to effective supervision of maternal and newborn care: a qualitative study from Shinyanga region, Tanzania. Glob Health Action 2021; 14:1927330. [PMID: 34148525 PMCID: PMC8216264 DOI: 10.1080/16549716.2021.1927330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Despite routine supportive supervision of health service delivery, maternal and newborn outcomes have remained poor in sub-Saharan Africa in general and in Tanzania in particular. There is limited research evidence on factors limiting the effectiveness of supportive supervision in improving the quality of maternal and newborn care. Objective: This study explored enablers of and barriers to supportive supervision in maternal and newborn care at the district and hospital levels in Shinyanga region in Tanzania. Methods: This study employed a qualitative case study design. A purposeful sampling approach was employed to recruit a stratified sample of health system actors: members of the council health management team (CHMT), members of health facility management teams (HMTs), heads of units in the maternity department and health workers. Results: This study identified several barriers to the effectiveness of supportive supervision. First, the lack of a clear policy on supportive supervision. Despite the general acknowledgement of supportive supervision as a managerial mechanism for quality improvement at the district and lower-level health facilities, there is no clear policy guiding it. Second, limitations in measurement of progress in quality improvement; although supportive supervision is routinely conducted to improve maternal and newborn outcomes, efforts to measure progress are limited due to shortfalls in the setting of goals and targets, as well as gaps in M&E. Third, resource constraints and low motivation; that is, the shortage of resources – CHMT supervisors, health staff and funds – results in irregular supervision and low motivation. Conclusion: Besides resource constraints, lack of clear policies and limitations related to progress measurement impair the effectiveness of supportive supervision in improving maternal and newborn outcomes. There is a need to reform supportive supervision so that it aids and measures progress not only at the district but also at the health facility level.
Collapse
Affiliation(s)
- Tumaini Mwita Nyamhanga
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Gasto Frumence
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Anna-Karin Hurtig
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| |
Collapse
|
26
|
Schaaf M, Warthin C, Freedman L, Topp SM. The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability. BMJ Glob Health 2021; 5:bmjgh-2020-002296. [PMID: 32546585 PMCID: PMC7299037 DOI: 10.1136/bmjgh-2020-002296] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022] Open
Abstract
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.
Collapse
Affiliation(s)
| | - Caitlin Warthin
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lynn Freedman
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| |
Collapse
|
27
|
Nelson C, Madiba S. Barriers to the Implementation of the Ward-Based Outreach Team Program in Mpumalanga Province: Results From Process Evaluation. J Prim Care Community Health 2021; 11:2150132720975552. [PMID: 33213270 PMCID: PMC7682205 DOI: 10.1177/2150132720975552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: South Africa adopted the ward-based outreach team (WBOT) program as one aspect of the three-stream approach to primary health care (PHC) re-engineering. PHC re-engineering seeks to modify the hospicentric and curative approach into a more preventive and promotive approach to improve health outcomes. There has not been an evaluation of the implementation of the WBOTs in Nkangala District since its inception in 2012. Methods: A process evaluation approach using qualitative methods was used to examine and describe the contextual, organizational, health provider, and program-related barriers considered to affect the implementation of the WBOTs 3 sub-districts in one of the health districts in Mpumalanga Province, South Africa. The framework for this evaluation was informed by the logic model framework developed by the Center for Disease Control as well as the 3 domains of evaluation recommended by the Medical Research Council Guidance on process evaluation. Data were collected through in-depth interviews with multiple data sources directly involved in the implementation of the WBOTs. A thematic analysis was done using NVivo 11. Results: The key critical barriers identified by the evaluation include the inadequate provision of resources, the lack of supervision, the heavy workload for outreach teams, the inadequate and irregular payment of stipends, threats to the safety of the CHWs, and the cultural beliefs and practices of the communities who are to receive the services. The lack of adequate financial resources was the main challenge, and will continue to pose a risk to the successful implementation of the WBOTs. Conclusions: Although the barriers are being reported as separate contextual factors, the internal and external contexts are interdependent, interact with one each other, and should not be considered in isolation. The need to improve stakeholder engagement on the WBOT program underscores the importance of the external context in the successful implementation of WBOTs.
Collapse
Affiliation(s)
- Cheryl Nelson
- Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
28
|
Gottert A, McClair TL, Hossain S, Dakouo SP, Abuya T, Kirk K, Bellows B, Agarwal S, Kennedy S, Warren C, Sripad P. Development and validation of a multi-dimensional scale to assess community health worker motivation. J Glob Health 2021; 11:07008. [PMID: 33763222 PMCID: PMC7957275 DOI: 10.7189/jogh.11.07008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Ensuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being - and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation. METHODS Scale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables. RESULTS The final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention. CONCLUSIONS We found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.
Collapse
Affiliation(s)
- Ann Gottert
- Population Council, Washington D.C. & New York, New York, USA
| | - Tracy L McClair
- Population Council, Washington D.C. & New York, New York, USA
| | | | | | | | - Karen Kirk
- Population Council, Washington D.C. & New York, New York, USA
| | - Ben Bellows
- Population Council, Washington D.C. & New York, New York, USA
| | - Smisha Agarwal
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sarah Kennedy
- Population Council, Washington D.C. & New York, New York, USA
| | | | - Pooja Sripad
- Population Council, Washington D.C. & New York, New York, USA
| |
Collapse
|
29
|
Laurenzi CA, Skeen S, Coetzee BJ, Notholi V, Gordon S, Chademana E, Bishop J, Tomlinson M. Instructive roles and supportive relationships: client perspectives of their engagement with community health workers in a rural south African home visiting program. Int J Equity Health 2021; 20:32. [PMID: 33436011 PMCID: PMC7805205 DOI: 10.1186/s12939-020-01377-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/28/2020] [Indexed: 11/12/2022] Open
Abstract
Background Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa. Methods We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February–March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients’ home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed. Results We found that clients’ home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother’s advice. Conclusions These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients’ voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-020-01377-z.
Collapse
Affiliation(s)
- Christina A Laurenzi
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa. .,Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
| | - Sarah Skeen
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Bronwynè J Coetzee
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Vuyolwethu Notholi
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Sarah Gordon
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Emma Chademana
- One to One Africa Children's Fund, Cape Town, South Africa
| | - Julia Bishop
- One to One Africa Children's Fund, Cape Town, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa.,School of Nursing and Midwifery, Queens University Belfast, Belfast, UK
| |
Collapse
|
30
|
O'Sullivan B, Chater B, Bingham A, Wynn-Jones J, Couper I, Hegazy NN, Kumar R, Lawson H, Martinez-Bianchi V, Randenikumara S, Rourke J, Strasser S, Worley P. A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries. Front Med (Lausanne) 2020; 7:594728. [PMID: 33330559 PMCID: PMC7729061 DOI: 10.3389/fmed.2020.594728] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.
Collapse
Affiliation(s)
- Belinda O'Sullivan
- Faculty of Medicine, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - Bruce Chater
- Faculty of Medicine, Rural Clinical School, University of Queensland, Theodore, QLD, Australia
| | - Amie Bingham
- Faculty of Medicine, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - John Wynn-Jones
- Keele Medical School, Keele University, Keele, United Kingdom
| | - Ian Couper
- Ukwanda Center for Rural Health, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Nagwa Nashat Hegazy
- Medical Education and Human Resources Center, Faculty of Medicine, Menoufia University, Shibin el Kom, Egypt
| | - Raman Kumar
- Family Medicine Practitioner, DOC24 Family Practice Clinic, Ghaziabad, India
| | - Henry Lawson
- Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | | | - James Rourke
- Center for Rural Health Studies, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Sarah Strasser
- Faculty of Medicine, Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
| | - Paul Worley
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| |
Collapse
|
31
|
Bagonza A, Peterson S, Mårtensson A, Mutto M, Awor P, Kitutu F, Gibson L, Wamani H. 'I know those people will be approachable and not mistreat us': a qualitative study of inspectors and private drug sellers' views on peer supervision in rural Uganda. Global Health 2020; 16:106. [PMID: 33109214 PMCID: PMC7590471 DOI: 10.1186/s12992-020-00636-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Peer supervision improves health care delivery by health workers. However, in rural Uganda, self-supervision is what is prescribed for licensed private drug sellers by statutory guidelines. Evidence shows that self-supervision encourages inappropriate treatment of children less than 5 years of age by private drug sellers. This study constructed a model for an appropriate peer supervisor to augment the self-supervision currently practiced by drug sellers at district level in rural Uganda. METHODS In this qualitative study, six Key informant interviews were held with inspectors while ten focus group discussions were conducted with 130 drug sellers. Data analysis was informed by the Kathy Charmaz constructive approach to grounded theory. Atlas ti.7 software package was used for data management. RESULTS A model with four dimensions defining an appropriate peer supervisor was developed. The dimensions included; incentives, clearly defined roles, mediation and role model peer supervisor. While all dimensions were regarded as being important, all participants interviewed agreed that incentives for peer supervisors were the most crucial. Overall, an appropriate peer supervisor was described as being exemplary to other drug sellers, operated within a defined framework, well facilitated to do their role and a good go-between drug sellers and government inspectors. CONCLUSION Four central contributions advance literature by the model developed by our study. First, the model fills a supervision gap for rural private drug sellers. Second, it highlights the need for terms of reference for peer supervisors. Third, it describes who an appropriate peer supervisor should be. Lastly, it elucidates the kind of resources needed for peer supervision.
Collapse
Affiliation(s)
- Arthur Bagonza
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
| | - Stefan Peterson
- Department of Health Policy Planning and Management, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
- Department of Women's and Children's Health, International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden
| | - Andreas Mårtensson
- Department of Women's and Children's Health, International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden
| | - Milton Mutto
- Department of Disease Control and Environmental Health, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Freddy Kitutu
- Department of Pharmacy, School of Health Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Henry Wamani
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| |
Collapse
|
32
|
Lewis J, LeBan K, Solomon R, Bisrat F, Usman S, Arale A. The Critical Role and Evaluation of Community Mobilizers in Polio Eradication in Remote Settings in Africa and Asia. GLOBAL HEALTH, SCIENCE AND PRACTICE 2020; 8:396-412. [PMID: 33008854 PMCID: PMC7541117 DOI: 10.9745/ghsp-d-20-00024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/12/2020] [Indexed: 01/05/2023]
Abstract
This article assesses the CORE Group Polio Project (CGPP) experience over a 20-year period in 5 countries. It examines how a program designed to provide social mobilization to eradicate one disease, and which did so effectively, functioned within the general framework of community health workers (CHWs). Vertical health programs often have limited impact on broader community health. CGPP has a 20-year history of social mobilization and effective program interventions. This history provided an opportunity to assess how CGPP community mobilizers (CMs) functioned in polio and maternal and child health. The Updated Program Functionality Matrix for Optimizing Community Health Programs tool of the CHW Assessment and Improvement Matrix (AIM) was used to examine CGPP CM roles across different contexts. The analysis determined that CGPP CMs met the basic level of functioning (level 3) for 6 of the 10 components of the AIM tool. This cross-country descriptive analysis of the CGPP demonstrates the importance of embracing the full range of CHW AIM components, even in a vertical program. Use of data, community involvement, local adaptation, and linkage with the health system are especially critical for success. This general lesson could be applied to other community mobilization and disease/epidemic control initiatives, especially as we face the issues of the COVID-19 pandemic.
Collapse
Affiliation(s)
- Judy Lewis
- University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Karen LeBan
- Global health consultant, Washington, DC, USA
| | | | | | - Samuel Usman
- CORE Group Polio Project Nigeria, Abuja, Nigeria
| | - Ahmed Arale
- CORE Group Polio Project Horn of Africa, Nairobi, Kenya
| |
Collapse
|
33
|
Brown O, Kangovi S, Wiggins N, Alvarado CS. Supervision Strategies and Community Health Worker Effectiveness in Health Care Settings. NAM Perspect 2020; 2020:202003c. [PMID: 34532677 DOI: 10.31478/202003c] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
34
|
Assegaai T, Schneider H. The supervisory relationships of community health workers in primary health care: social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa. BMJ Glob Health 2019; 4:e001839. [PMID: 31908861 PMCID: PMC6936529 DOI: 10.1136/bmjgh-2019-001839] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/13/2019] [Accepted: 11/19/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction Supportive supervision remains a key challenge to the sustainability of community health worker (CHW) programmes globally. The aim of the study was to identify critical actors and patterns of relationships in the supervision of ward-based outreach teams (WBOT) in a rural South African district. Methods A cross-sectional study of social and professional relationships of WBOTs with other primary health care (PHC) system actors was conducted using a social network analysis (SNA) approach. A structured questionnaire was distributed to CHWs (37), WBOT team leaders (3), PHC facility managers (5) and PHC local area managers (2) (total n=47) assessing interaction patterns of supportive supervision, namely management, development and support. Results The supportive supervision system pivoted around team leaders, who were nurse cadres and who ensured internal cohesion and support among WBOT members. The network patterns also showed the extent of peer support between CHWs in WBOTs. PHC facility staff and middle managers in the subdistrict did not appear to play active roles in the supervision of CHWs and their team leaders. However, there were exceptions, with WBOTs drawing on sympathetic cadres identified among the PHC facility staff for support. Conclusion Supportive supervision of CHWs can be thought of as a system of horizontal and vertical relationships that go beyond just one supervisor–supervisee interaction. In this study, supervisory relationships within teams functioned better than those between teams and the rest of the PHC system. Understanding these relationships is key to designing effective supportive supervision in CHW programmes. SNA can be a valuable approach in identifying the relationships to be strengthened.
Collapse
Affiliation(s)
- Tumelo Assegaai
- School of Public Health, University of the Western Cape Faculty of Community and Health Sciences, Cape Town, South Africa
| | - Helen Schneider
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| |
Collapse
|
35
|
Bunger AC, Birken SA, Hoffman JA, MacDowell H, Choy-Brown M, Magier E. Elucidating the influence of supervisors' roles on implementation climate. Implement Sci 2019; 14:93. [PMID: 31653254 PMCID: PMC6815002 DOI: 10.1186/s13012-019-0939-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/11/2019] [Indexed: 11/20/2022] Open
Abstract
Background Supervisors play an essential role in implementation by diffusing and synthesizing information, selling implementation, and translating top management’s project plans to frontline workers. Theory and emerging evidence suggest that through these roles, supervisors shape implementation climate—i.e., the degree to which innovations are expected, supported, and rewarded. However, it is unclear exactly how supervisors carry out each of these roles in ways that contribute to implementation climate—this represents a gap in the understanding of the causal mechanisms that link supervisors’ behavior with implementation climate. This study examined how supervisors’ performance of each of these roles influences three core implementation climate domains (expectations, supports, and rewards). Materials and methods A sequenced behavioral health screening, assessment, and referral intervention was implemented within a county-based child welfare agency. We conducted 6 focus groups with supervisors and frontline workers from implementing work units 6 months post-implementation (n = 51) and 1 year later (n = 40) (12 groups total). Participants were asked about implementation determinants, including supervision and implementation context. We audio-recorded, transcribed, and analyzed focus groups using an open coding process during which the importance of the supervisors’ roles emerged as a major theme. We further analyzed this code using concepts and definitions related to middle managers’ roles and implementation climate. Results In this work setting, supervisors (1) diffused information about the intervention proactively, and in response to workers’ questions, (2) synthesized information by tailoring it to workers’ individual needs, (3) translated top managements’ project plans into day-to-day tasks through close monitoring and reminders, and (4) justified implementation. All four of these roles appeared to shape the implementation climate by conveying strong expectations for implementation. Three roles (diffusing, synthesizing, and mediating) influenced climate by supporting workers during implementation. Only one role (diffusing) influenced climate by conveying rewards. Conclusions Supervisors shaped implementation climate by carrying out four roles (diffusing, synthesizing, mediating, and selling). Findings suggest that the interaction of these roles convey expectations and support for implementation (two implementation climate domains). Our study advances the causal theory explaining how supervisors’ behavior shapes the implementation climate, which can inform implementation practice.
Collapse
Affiliation(s)
- Alicia C Bunger
- College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH, 43210, USA.
| | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105C McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill, NC, 27599, USA
| | - Jill A Hoffman
- School of Social Work, Portland State University, 1800 SW 6th Avenue, Suite 600, Portland, OR, 97201, USA
| | - Hannah MacDowell
- Bureau of Maternal, Child and Family Health, Ohio Department of Health, 246 North High Street, Columbus, OH, 43215, USA
| | - Mimi Choy-Brown
- School of Social Work, University of Minnesota, Peters Hall, 1404 Gortner Ave, Saint Paul, MN, 55108, USA
| | - Erica Magier
- College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH, 43210, USA
| |
Collapse
|
36
|
Nass SS, Isah MB, Sani A. Effect of Integrated Supportive Supervision on the Quality of Health-Care Service Delivery in Katsina State, Northwest Nigeria. Health Serv Res Manag Epidemiol 2019; 6:2333392819878619. [PMID: 31633000 PMCID: PMC6767721 DOI: 10.1177/2333392819878619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Katsina State Government in Northern Nigeria introduced integrated supportive
supervision (ISS) in primary health centers. The study was guided by the Primary Health
Care Performance Initiative Conceptual Framework. The goal of the study was to measure
the impact of ISS on the quality of primary health-care delivery. The outcome variables
measured include infrastructure, basic equipment, human resources for health, essential
drugs, the number of pregnant women screened for HIV, and the number of children
receiving immunization. Methods: The study was a cross-sectional survey of 34 health facilities. Kruskal-Wallis
nonparametric test followed by Dunn post hoc test and analysis of variance followed by
Tukey post hoc test were both employed to compare the mean values of various indicators
obtained over 6 visits of the ISS program from July 2018 to December 2018. Findings: The study shows the positive effect of the ISS on infrastructure, human resources for
health, essential drugs, and the number of pregnant women screened for HIV
(P < .05). Human resources for health and the number of children
receiving immunization were both not affected by ISS (P > .05). Conclusion: Integrated supportive supervision need to be embedded into the 3 levels (primary,
secondary, and tertiary) of health-care service delivery. Implications: Integrated supportive supervision will strengthen the Katsina State health system,
ensure efficient use of the health facility assets and resources utilization, and
improve patient/client satisfaction.
Collapse
Affiliation(s)
| | | | - Aminu Sani
- World Health Organization, North-West Zonal Office, Nigeria
| |
Collapse
|
37
|
Avortri GS, Nabukalu JB, Nabyonga-Orem J. Supportive supervision to improve service delivery in low-income countries: is there a conceptual problem or a strategy problem? BMJ Glob Health 2019; 4:e001151. [PMID: 31673434 PMCID: PMC6797347 DOI: 10.1136/bmjgh-2018-001151] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/07/2018] [Accepted: 11/23/2018] [Indexed: 12/24/2022] Open
Abstract
Supportive supervision is perceived as an intervention that strengthens the health system, enables health workers to offer quality services and improve performance. Unfortunately, numerous studies show that supervisory mechanisms in many low-income countries (LICs) are suboptimal. Further, the understanding of the concept and its implementation is still shrouded in misinterpretations and inconsistencies. This analysis contributes to a deeper understanding of the concept of supportive supervision and how reorganisation of the approach can contribute to improved performance. The effectiveness of supportive supervision is mixed, with some studies noting that evidence on its role, especially in LICs is inconclusive. Quality of care is a core component of universal health coverage which, accentuates the need for supportive supervision. In the context of LICs, it is imperative for supportive supervision to be implemented as an on-going approach. Factors that affect supportive supervision encompass cultural, social, organizational and context dimensions but the capacity of majority of LIC to address these is limited. To this end, we underscore the need to review the supportive supervision approach to improve its effectiveness, and ensure that facility-based supervision embodies as many of the envisioned qualities as possible. We thus make a case for a stronger focus on internal supportive supervision where internal refers to health facility/unit/ward level. Inherent in the approach is what we refer to as ‘supervisee initiated supportive supervision’. The success of this approach must be anchored on a strong system for monitoring, data and information management at the health facility level.
Collapse
Affiliation(s)
- Gertrude Sika Avortri
- Health Systems and Services Cluster, World Health Organization, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe
| | | | - Juliet Nabyonga-Orem
- Health Systems and Services Cluster, World Health Organization, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe
| |
Collapse
|
38
|
Kim C, Kirunda R, Mubiru F, Rakhmanova N, Wynne L. A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda. Gates Open Res 2019; 3:1481. [PMID: 31392298 PMCID: PMC6650767 DOI: 10.12688/gatesopenres.12973.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2019] [Indexed: 11/20/2022] Open
Abstract
Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention. Methods: We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions. Results: The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled. Conclusions: A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.
Collapse
Affiliation(s)
- Christine Kim
- Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7411, USA
| | | | | | | | - Leigh Wynne
- FHI 360, 359 Blackwell Street #200, Durham, NC, 27701, USA
| |
Collapse
|
39
|
Griffiths F, Babalola O, Brown C, de Kadt J, Malatji H, Thorogood M, Tseng YH, Goudge J. Development of a tool for assessing quality of comprehensive care provided by community health workers in a community-based care programme in South Africa. BMJ Open 2019; 9:e030677. [PMID: 31492789 PMCID: PMC6731907 DOI: 10.1136/bmjopen-2019-030677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To develop a tool for use by non-clinical fieldworkers for assessing the quality of care delivered by community health workers providing comprehensive care in households in low- and middle-income countries. DESIGN We determined the content of the tool using multiple sources of information, including interactions with district managers, national training manuals and an exploratory study that included observations of 70 community health workers undertaking 518 household visits collected as part of a wider study. We also reviewed relevant literature, selecting relevant domains and quality markers. To refine the tool and manual we worked with the fieldworkers who had undertaken the observations. We constructed two scores summarising key aspects of care: (1) delivering messages and actions during household visit, and (2) communicating with the household; we also collected contextual data. The fieldworkers used the tool with community health workers in a different area to test feasibility. SETTING South Africa, where community health workers have been brought into the public health system to address the shortage of healthcare workers and limited access to healthcare. It was embedded in an intervention study to improve quality of community health worker supervision. PRIMARY AND SECONDARY OUTCOMES Our primary outcome was the completion of a tool and user manual. RESULTS The tool consists of four sections, completed at different stages during community health worker household visits: before setting out, at entry to a household, during the household visit and after leaving the household. Following tool refinement, we found no problems on field-testing the tool. CONCLUSIONS We have developed a tool for assessing quality of care delivered by community health workers at home visits, often an unobserved part of their role. The tool was developed for evaluating an intervention but could also be used to support training and management of community health workers.
Collapse
Affiliation(s)
- Frances Griffiths
- University of Warwick Warwick Medical School, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Olukemi Babalola
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Celia Brown
- University of Warwick Warwick Medical School, Coventry, UK
| | - Julia de Kadt
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Hlologelo Malatji
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Margaret Thorogood
- University of Warwick Warwick Medical School, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Yu-Hwei Tseng
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Jane Goudge
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| |
Collapse
|
40
|
Kim C, Kirunda R, Mubiru F, Rakhmanova N, Wynne L. A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda. Gates Open Res 2019; 3:1481. [DOI: 10.12688/gatesopenres.12973.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 11/20/2022] Open
Abstract
Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.Methods:We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions.Results:The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled.Conclusions:A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.
Collapse
|
41
|
Assegaai T, Schneider H. National guidance and district-level practices in the supervision of community health workers in South Africa: a qualitative study. HUMAN RESOURCES FOR HEALTH 2019; 17:25. [PMID: 30943986 PMCID: PMC6446406 DOI: 10.1186/s12960-019-0360-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/11/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Supportive supervision is considered critical to community health worker programme performance, but there is relatively little understanding of how it can be sustainably done at scale. Supportive supervision is a holistic concept that encompasses three key functions: management (ensuring performance), education (promoting development) and support (responding to needs and problems). Drawing on the experiences of the ward-based outreach team (WBOT) strategy, South Africa's national community health worker (CHW) programme, this paper explores and describes approaches to supportive supervision in policy and programme guidelines and how these are implemented in supervision practices in the North West Province, an early adopter of the WBOT strategy. Outreach teams typically consist of six CHWs plus a nurse outreach team leader (OTL). METHODS A qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province was conducted. An overall WBOT policy statement and four guidelines on aspects of the strategy, spanning the period 2011-2017, were reviewed for statements on the three core facets of supervision outlined above. Eight focus group discussions, involving facility managers, team leaders and community health workers (total 40 respondents), purposively selected from four sub-districts in two districts, assessed local-level supervision practices. Alignment across policy and guidance documents and between policy/guidance and practice was examined. FINDINGS While all the official policy documents and guidelines reviewed acknowledged the need for supervision and support, these elements were inadequately developed and poorly aligned, both in terms of scope and in providing firm guidance on the supervision of WBOTs. The practices of supervision entailed a variety of reporting lines, while development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams amongst CHWs and between CHWs and OTLs. However, primary health care clinic managers, who were supposed to supervise the WBOTs, struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained. CONCLUSION This study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit, coherent and holistic guidance in policy and the failure to address constraints to supervision at local level undermine the performance and sustainability of the WBOT strategy in South Africa.
Collapse
Affiliation(s)
- Tumelo Assegaai
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Helen Schneider
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- University of the Western Cape/South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa
| |
Collapse
|
42
|
Kok MC, Vallières F, Tulloch O, Kumar MB, Kea AZ, Karuga R, Ndima SD, Chikaphupha K, Theobald S, Taegtmeyer M. Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries. Health Policy Plan 2018; 33:988-998. [PMID: 30247571 PMCID: PMC6263021 DOI: 10.1093/heapol/czy082] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 01/27/2023] Open
Abstract
Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs' perceptions of supervision and CHW motivation-related outcomes. In total, 153 in-depth interviews were conducted with CHWs, their supervisors and managers. In addition, questionnaires assessing perceived supervision and motivation-related outcomes (organizational and community commitment, job satisfaction and conscientiousness) were administered to a total of 278 CHWs pre- and post-intervention, and again after 1 year. Interview transcripts were thematically analysed using a coding framework. Changes in perceived supervision and motivation-related outcomes were assessed using Friedman's ANOVA and post hoc Wilcoxon signed-rank tests. Interview participants reported that the supervision intervention improved CHW motivation. In contrast, the quantitative survey found no significant changes for measures of perceived supervision and inconsistent changes in motivation-related outcomes. With regard to the process of supervision, the problem-solving focus, the sense of joint responsibilities and team work, cross-learning and skill sharing, as well as the facilitating and coaching role of the supervisor, were valued. The empowerment and participation of supervisees in decision making also emerged in the analysis, albeit to a lesser extent. Although qualitative and quantitative findings differed, which could be related to the slightly different focus of methods used and a 'ceiling effect' limiting the detection of observable differences from the survey, the study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance.
Collapse
Affiliation(s)
- Maryse C Kok
- KIT Health, Royal Tropical Institute, HA Amsterdam, The Netherlands
| | - Frédérique Vallières
- Centre for Global Health, School of Psychology, Trinity College, 709 Leinster Street South, Dublin 2, Ireland
| | - Olivia Tulloch
- Options Consultancy Services, 3 Lower Thames Street, London, UK
| | - Meghan B Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Robinson Karuga
- Research and Strategic Information Department, LVCT Health, Nairobi, Kenya
| | - Sozinho D Ndima
- Department of Community Health, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Sally Theobald
- Options Consultancy Services, 3 Lower Thames Street, London, UK
| | | |
Collapse
|