Factors influencing the performance of community health volunteers working within urban informal settlements in low- and middle-income countries: a qualitative meta-synthesis review

Do cash or digital payment modalities affect community health worker performance? - a case study of a remote refugee settlement in Western Uganda

BACKGROUND

There is inadequate evidence about the influence of digital and cash payment modalities on the performance of Community Health Workers (CHWs) in underserved communities, such as refugee settlements.

OBJECTIVE

To compare the performance of CHWs when paid in cash or digitally in Kyaka II refugee settlement, Uganda.

METHODS

A comparative cross-sectional mixed methods design was used. Secondary data comprising 247 CHW reports during a six-month period of cash and digital payments were analyzed using Stata v14. Eleven focus group discussions, four in-depth interviews, and ten key informant interviews were conducted among the settlement stakeholders to explore perceptions of the payment methods. Qualitative data were analyzed thematically using Atlas.ti v9.

RESULTS

CHWs performed better when paid cash than digital payments (t = 5.28; df = 246; p < 0.001). During the cash payment period, at least secondary education (APR 1.71 CI: 1.14-2.58) and having a side occupation (APR 1.58; CI: 1.13-2.21) were positively associated with performance. For digital payments, being male (APR 0.58; CI: 0.34-0.98), serving longer than 9 years (APR 0.87; CI: 0.82-0.93), and being allocated more than 60 households per month (APR 0.31; CI: 0.19-0.52) were negatively associated with CHW performance. Qualitative data revealed that most stakeholders preferred cash due to inconsistent and delayed digital payments.

CONCLUSION

CHWs preferred and performed better with cash payments because digital payments were associated with delays and payment shortfalls that demotivated them. Implementers should invest towards averting digital payment shortfalls in remote settings to enhance CHW motivation and performance.

Need for operational simplicity and timely disbursal of benefits-a qualitative exploration of the implementation of a direct benefit transfer scheme for persons with tuberculosis in India

BACKGROUND

Ni-kshay Poshan Yojana (NPY) is a direct benefit transfer scheme of the Government of India introduced in 2018 to support the additional nutritional requirements of persons with TB (PwTB). Our recent nationwide evaluation of implementation and utilization of NPY using programmatic data of PwTB from nine randomly selected Indian states, reported a 70% coverage and high median delay in benefit credit. We undertook a qualitative study between January and July 2023, to understand the detailed implementation process of NPY and explore the enablers and barriers to effective implementation and utilization of the NPY scheme.

METHODS

We followed a grounded theory approach to inductively develop theoretical explanations for social phenomena through data generated from multiple sources. We conducted 36 in-depth interviews of national, district and field-level staff of the National Tuberculosis Elimination Programme (NTEP) and NPY beneficiaries from 30 districts across nine states of India, selected using theoretical sampling. An analytical framework developed through inductive coding of a set of six interviews, guided the coding of the subsequent interviews. Categories and themes emerged through constant comparison and the data collection continued until theoretical saturation.

RESULTS

Stakeholders perceived NPY as a beneficial initiative. Strong political commitment from the state administration, mainstreaming of NTEP work with the district public healthcare delivery system, availability of good geographic and internet connectivity and state-specific grievance redressal mechanisms and innovations were identified as enablers of implementation. However, the complex, multi-level benefit approval process, difficulties in accessing banking services, perceived inadequacy of benefits and overworked human resources in the NTEP were identified as barriers to implementation and utilization.

CONCLUSION

The optimal utilization of NPY is enabled by strong political commitment and challenged by its lengthy implementation process and delayed disbursal of benefits. We recommend greater operational simplicity in NPY implementation, integrating NTEP activities with the public health system to reduce the burden on the program staff, and revising the benefit amount more equitably.

Meta-analysis of KAP toward COVID-19 in Chinese residents

Background

During the coronavirus disease-2019 (COVID-19) pandemic, there have been many studies on knowledge, attitudes, and practices (KAP) toward prevention of COVID-19 infection in China. Except for symptomatic treatment and vaccination, KAP toward COVID-19 plays an important role in the prevention of COVID-19. There is no systematic evaluation and meta-analysis of KAP toward COVID-19 in China. This study is the earliest meta-analysis of KAP toward COVID-19 in China's general population. Hence, this systematic review aimed to summarize the knowledge, attitudes, and practices (KAP) of Chinese residents toward COVID-19 during the pandemic.

Methodology

Following the PRISMA guidelines, articles relevant to COVID-19 KAP that were conducted among the Chinese population were found in databases such as Scopus, ProQuest, PubMed, EMbase, Web of Science, Cochrane Library, China Biology Medicine, China National Knowledge Infrastructure, CQVIP, Wanfang and Google Scholar. A random-effect meta-analysis is used to summarize studies on knowledge, attitudes, and practice levels toward COVID-19 infection in China's general population.

Results

Fifty-seven articles published between August 2020 and November 2022 were included in this review. Overall, 75% (95% CI: 72-79%) of Chinese residents had good knowledge about COVID-19, 80% (95% CI: 73-87%) of Chinese residents had a positive attitude toward COVID-19 pandemic control and prevention (they believe that Chinese people will win the battle against the epidemic), and the aggregated proportion of residents with a correct practice toward COVID-19 was 84% (95% CI: 82-87%, I2 = 99.7%).In the gender subgroup analysis, there is no significant difference between Chinese men and Chinese women in terms of their understanding of COVID-19. However, Chinese women tend to have slightly higher levels of knowledge and a more positive attitude toward the virus compared to Chinese men. When considering the urban and rural subgroup analysis, it was found that Chinese urban residents have a better understanding of COVID-19 compared to Chinese rural residents. Interestingly, the rural population displayed higher rates of correct behavior and positive attitudes toward COVID-19 compared to the urban population. Furthermore, in the subgroup analysis based on different regions in China, the eastern, central, and southwestern regions exhibited higher levels of knowledge awareness compared to other regions. It is worth noting that all regions in China demonstrated good rates of correct behavior and positive attitudes toward COVID-19.

Conclusion

This study reviews the level of KAP toward COVID-19 during the pandemic period in China. The results show that the KAP toward COVID-19 in Chinese residents was above a favorable level, but the lack of translation of knowledge into practice should be further reflected on and improved. A subgroup analysis suggests that certain groups need more attention, such as males and people living in rural areas. Policy makers should pay attention to the results of this study and use them as a reference for the development of prevention and control strategies for major public health events that may occur in the future.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=348246, CRD42022348246.

Does mHealth influence community health worker performance in vulnerable populations? A mixed methods study in a multinational refugee settlement in Uganda

Community Health Workers (CHWs) provide healthcare in under-served communities, including refugee settlements, despite various challenges hindering their performance. Implementers have adopted mobile wireless technologies (m-Health) to improve the performance of CHWs in refugee settlements. We assessed the CHWs' performance and associated factors in a multi-national refugee settlement, operating mHealth and paper-based methods. This cross-sectional study employed quantitative and qualitative data collection methods. Data for 300 CHWs was collected from implementing partners' (IPs) databases. Nine focus group discussions (FGDs) with the CHWs and community members, two in-depth interviews (IDIs) with CHW leaders, and eight key informant interviews (KIIs) with six IPs and two local leaders were conducted. The qualitative data were analysed thematically using AtlasTi version 9 while the quantitative data were analysed at the univariate, bivariate and multivariable levels using Stata version14. The study found that only 17% of the CHWs performed optimally. The factors that significantly influenced CHW performance included education level: secondary and above (APR: 1.83, 95% CI: 1.02-3.30), having a side occupation (APR: 2.02, 95% CI: 1.16-3.52) and mHealth use (APR: 0.06, 95% CI: 0.02-.0.30). The qualitative data suggested that performance was influenced by the number of households assigned to CHWs, monetary incentives, adequacy of materials and facilitation. Particularly, mHealth was preferred to paper-based methods. Overall, the CHWs' performance was sub-optimal; only 2 in 10 performed satisfactorily. The main factors that influenced performance included the level of education, use of mHealth, having another occupation, workload and incentivisation. CHWs and IPs preferred mHealth to paper-based methods. IPs should work to improve refugee settlement working conditions for the CHWs and adopt mHealth to improve CHW performance.

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

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

Vulnerable or resilient? The response of informal settlements to COVID-19: The case of urban village communities in Beijing

The COVID-19 pandemic has brought topics of the impact, response and adaptation of cities in emergencies to the forefront. When compared with formal settlements, the problems faced by informal settlements are more prominent. We propose the framework of an actor-network theory, substantiated by an empirical study of three typical informal settlements in Haidian District, Beijing, in which the process, characteristics and internal mechanism of the spatial reconstruction of the informal settlements in response to COVID-19 are closely scrutinised. Human actors such as local governments, community volunteers, landlords, tenants and non-human actors all participated in the response to COVID-19 according to their goal vision and political logic, with the local government as the core driving force, forming an integrated actor network. Rooted in the special locality of informal settlements, the actor network was both hierarchical and flexible, and its inherent dynamism has proven to be efficient during COVID-19, resulting in social adaptation and spatial reconstruction. This study contributes to the cautiously optimistic estimate of similar urban community resilience in terms of global epidemics and enriches the understanding of their interlacing dynamics from the perspective of spatial reconstruction.

'You say you are a TB doctor, but actually, you do not have any power': health worker (de)motivation in the context of integrated, hospital-based tuberculosis care in eastern China

BACKGROUND

In China, tuberculosis (TB) care, traditionally provided through the Centre for Disease Control (CDC), has been integrated into 'designated' public hospitals at County level, with hospital staff taking on delivery of TB services supported by CDC staff. Little is known about the impact of this initiative on the hospital-based health workers who were delegated to manage TB. Drawing on a case study of two TB 'designated' hospitals in Zhejiang province, we explored factors influencing hospital-based health workers' motivation in the context of integrated TB service delivery.

METHODS

We conducted 47 in-depth interviews with health officials, TB/hospital managers, clinicians, radiologists, laboratory staff and nurses involved in the integrated model of hospital-based TB care. Thematic analysis was used to develop and refine themes, code the data and assist in interpretation.

RESULTS

Health workers tasked with TB care in 'designated' hospitals perceived their professional status to be low, related to their assessment of TB treatment as lacking need for professional skills, their limited opportunities for professional development, and the social stigma surrounding TB. In both sites, the integrated TB clinics were under-staffed: health workers providing TB care reported heavy workloads, and expressed dissatisfaction with a perceived gap in their salaries compared with other clinical staff. In both sites, health workers were concerned about poor infection control and weak risk management assessment systems.

CONCLUSIONS

Inadequate attention to workforce issues for TB control in China, specifically the professional status, welfare, and development as well as incentivization of infectious disease control workers has contributed to dissatisfaction and consequently poor motivation to serve TB patients within the integrated model of TB care. It is important to address the failure to motivate health workers and maximize public good-oriented TB service provision through improved government funding and attention to the professional welfare of health workers providing TB care in hospitals.