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Engeda EH, Aldersey HM, Davison CM, Gelaye KA, Fayed N. Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework. PLoS One 2024; 19:e0298769. [PMID: 38696368 PMCID: PMC11065226 DOI: 10.1371/journal.pone.0298769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 01/31/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change. METHODS A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors. RESULTS Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive. CONCLUSIONS The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.
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Affiliation(s)
- Eshetu Haileselassie Engeda
- Department of Pediatric and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Heather M. Aldersey
- Queen’s University School of Rehabilitation Therapy, Kingston, Ontario, Canada
| | - Colleen M. Davison
- Department of Public Health Sciences, Queen’s University Kingston, Kingston, Ontario, Canada
| | - Kassahun Alemu Gelaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nora Fayed
- Queen’s University School of Rehabilitation Therapy, Kingston, Ontario, Canada
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Shawon RA, Denno D, Tickell KD, Atuhairwe M, Bandsma R, Mupere E, Voskuijl W, Mbale E, Ahmed T, Chisti MJ, Saleem AF, Ngari M, Diallo AH, Berkley J, Walson J, Means AR. Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study. BMJ Open 2024; 14:e078404. [PMID: 38458789 DOI: 10.1136/bmjopen-2023-078404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVES This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings. DESIGN AND SETTING We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries. PARTICIPANTS A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study. PRIMARY OUTCOME MEASURES We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations. RESULTS Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted. CONCLUSIONS Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.
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Affiliation(s)
- Riffat Ara Shawon
- Epidemiology, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
| | - Donna Denno
- Global Health, University of Washington, Seattle, Washington, USA
- Pediatrics, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Kirkby D Tickell
- Epidemiology, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Michael Atuhairwe
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Uganda-Case Western Reserve University Research Collaboration, Makerere University, Kampala, Uganda
| | - Robert Bandsma
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Centre for Global Child Health, Toronto, Ontario, Canada
| | - Ezekiel Mupere
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Uganda-Case Western Reserve University Research Collaboration, Makerere University, Kampala, Uganda
- Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Wieger Voskuijl
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Kamuzu University for Health Sciences, Blantyre, Malawi
| | - Emmie Mbale
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Pediatrics, University of Malawi, Blantyre, Malawi
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - James Berkley
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Judd Walson
- Epidemiology, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
- Pediatrics, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Migowa A, Bernatsky S, Ngugi AK, Foster HE, Muriuki P, Riang'a RM, Luchters S. Bridging gaps: a qualitative inquiry on improving paediatric rheumatology care among healthcare workers in Kenya. Pediatr Rheumatol Online J 2023; 21:144. [PMID: 38093255 PMCID: PMC10717234 DOI: 10.1186/s12969-023-00935-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Due to the paucity of paediatric rheumatologists in Kenya, it is paramount that we explore strategies to bridge clinical care gaps for paediatric rheumatology patients in order to promote early diagnosis, prompt referral, and optimal management. PURPOSE To identify proposed interventions which can improve the ability of non-specialist healthcare workers to care for paediatric rheumatology patients across Kenya. METHODS We conducted 12 focus group discussions with clinical officers (community physician assistants), nurses, general practitioners and paediatricians across six regions in Kenya. Interviews were conducted, audio-recorded, transcribed verbatim, and analysed using MAXQDA 2022.2 software. RESULTS A total of 68 individuals participated in the study; 11 clinical officers, 12 nurses, 10 general practitioners, 27 paediatricians and eight other healthcare workers. Proposed patient interventions included patient education and psychosocial support. Community interventions were outreach awareness campaigns, mobilising financial support for patients' care, mobilising patients to access diagnostic and therapeutic interventions. Healthcare worker interventions include diagnostic, management, and referral guidelines, as well as research and educational interventions related to symptom identification, therapeutic strategies, and effective patient communication skills. In addition, it was highlighted that healthcare systems should be bolstered to improve insurance coverage and access to integrated multi-disciplinary clinical care. CONCLUSIONS Study participants were able to identify potential initiatives to improve paediatric rheumatology care in Kenya. Additional efforts are underway to design, implement and monitor the impact of some of these potential interventions.
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Affiliation(s)
- Angela Migowa
- Department of Paediatrics and Child Health, Aga Khan University, Medical College East Africa, Nairobi, Kenya.
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Sasha Bernatsky
- Department of Medicine (Divisions of Rheumatology and Clinical Epidemiology), McGill University Health Centre (MUHC), Montréal, Canada
| | - Anthony K Ngugi
- Department of Population Health, Aga Khan University East Africa, Nairobi, Kenya
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Centre for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
| | - Helen E Foster
- Population and Health Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peterrock Muriuki
- African Population and Health Research Centre (APHRC), Nairobi, Kenya
| | - Roselyter M Riang'a
- Department of Population Health, Aga Khan University East Africa, Nairobi, Kenya
| | - Stanley Luchters
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
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Schuetze L, Srivastava S, Kuunibe N, Rwezaula EJ, Missenye A, Stoermer M, De Allegri M. What Factors Explain Low Adoption of Digital Technologies for Health Financing in an Insurance Setting? Novel Evidence From a Quantitative Panel Study on IMIS in Tanzania. Int J Health Policy Manag 2023; 12:6896. [PMID: 37579470 PMCID: PMC10125074 DOI: 10.34172/ijhpm.2023.6896] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Digital information management systems for health financing are implemented on the assumption thatdigitalization, among other things, enables strategic purchasing. However, little is known about the extent to which thesesystems are adopted as planned to achieve desired results. This study assesses the levels of, and the factors associated withthe adoption of the Insurance Management Information System (IMIS) by healthcare providers in Tanzania. METHODS Combining multiple data sources, we estimated IMIS adoption levels for 365 first-line health facilities in2017 by comparing IMIS claim data (verified claims) with the number of expected claims. We defined adoption as abinary outcome capturing underreporting (verified RESULTS We found a median (interquartile range [IQR]) difference of 77.8% (32.7-100) between expected and verifiedclaims, showing a consistent pattern of underreporting across districts, regions, and months. Levels of underreportingvaried across regions (ANOVA: F=7.24, P<.001) and districts (ANOVA: F=4.65, P<.001). Logistic regression resultsshowed that higher service volume, share of people insured, and greater distance to district headquarter were associatedwith a higher probability of underreporting. CONCLUSION Our study shows that the adoption of IMIS in Tanzania may be sub-optimal and far from policy-makers'expectations, limiting its capacity to provide the necessary information to enhance strategic purchasing in the healthsector. Countries and agencies adopting digital interventions such as openIMIS to foster health financing reform areadvised to closely track their implementation efforts to make sure the data they rely on is accurate. Further, our studysuggests organizational and infrastructural barriers beyond the software itself hamper effective adoption.
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Affiliation(s)
- Leon Schuetze
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Siddharth Srivastava
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Naasegnibe Kuunibe
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Faculty of Integrated Development Studies, University for Development Studies, Wa, Ghana
| | | | | | - Manfred Stoermer
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
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Abdalla S, Pair E, Mehta K, Ward V, Mahapatra T, Darmstadt GL. Improving the precision of maternal, newborn, and child health impact through geospatial analysis of the association of contextual and programmatic factors with health trends in Bihar, India. J Glob Health 2022; 12:04064. [PMID: 36412069 PMCID: PMC9679706 DOI: 10.7189/jogh.12.04064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background There is a scarcity of research that comprehensively examines programme impact from a context-specific perspective. We aimed to determine the conditions under which the Bihar Technical Support Programme led to more favourable outcomes for maternal and child health in Bihar. Methods We obtained block-level data on maternal and child health indicators during the state-wide scale-up of the pilot Ananya programme and data on health facility readiness, along with geographical and sociodemographic variables. We examined the associations of these factors with increases in the levels of indicators using multilevel logistic regression, and the associations with rates of change in the indicators using Bayesian Hierarchical modelling. Results Frontline worker (FLW) visits between 2014-2017 were more likely to increase in blocks with better night lighting (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.01-1.51). Birth preparedness increased in blocks with increasing FLW visits (OR = 3.43, 95% CI = 1.15-10.21), while dry cord care practice increased in blocks where satisfaction with FLW visits was increasing (OR = 1.52, 95% CI = 1.10-2.11). Age-appropriate frequency of complementary feeding increased in blocks with higher development index (OR = 1.55, 95% CI = 1.16-2.06) and a higher percentage of scheduled caste or tribe (OR = 3.21, 95% CI = 1.13-9.09). An increase in most outcomes was more likely in areas with lower baseline levels. Conclusions Contextual factors (eg, night lighting and development) not targeted by the programme and FLW visits were associated with favourable programme outcomes. Intervention design, including intervention selection for a particular geography, should be modified to fit the local context in the short term. Expanding collaborations beyond the health sector to influence modifiable contextual factors in the long term can result in a higher magnitude and more sustainable impact. Registration ClinicalTrials.gov: NCT02726230.
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Affiliation(s)
- Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Emma Pair
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kala Mehta
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Victoria Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Ogola M, Njuguna EM, Aluvaala J, English M, Irimu G. Audit identified modifiable factors in Hospital Care of Newborns in low-middle income countries: a scoping review. BMC Pediatr 2022; 22:99. [PMID: 35180843 PMCID: PMC8855576 DOI: 10.1186/s12887-021-02965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/19/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Audit of facility-based care provided to small and sick newborns is a quality improvement initiative that helps to identify the modifiable gaps in newborn care (BMC Pregnancy Childbirth 14: 280, 2014). The aim of this work was to identify literature on modifiable factors in the care of newborns in the newborn units in health facilities in low-middle-income countries (LMICs). We also set out to design a measure of the quality of the perinatal and newborn audit process. METHODS The scoping review was conducted using the methodology outlined by Arksey and O'Malley and refined by Levac et al, (Implement Sci 5:1-9, 2010). We reported our results using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We identified seven factors to ensure a successful audit process based on World Health Organisation (WHO) recommendations which we subsequently used to develop a quality of audit process score. DATA SOURCES We conducted a structured search using PubMed, CINAHL, EMBASE, LILACS, POPLINE and African Index Medicus. STUDY SELECTION Studies published in English between 1965 and December 2019 focusing on the identification of modifiable factors through clinical or mortality audits in newborn care in health facilities from LMICs. DATA EXTRACTION We extracted data on the study characteristics, modifiable factors and quality of audit process indicators. RESULTS A total of six articles met the inclusion criteria. Of these, four were mortality audit studies and two were clinical audit studies that we used to assess the quality of the audit process. None of the studies were well conducted, two were moderately well conducted, and four were poorly conducted. The modifiable factors were divided into three time periods along the continuum of newborn care. The period of newborn unit care had the highest number of modifiable factors, and in each period, the health worker related modifiable factors were the most dominant. CONCLUSION Based on the significant number of modifiable factors in the newborn unit, a neonatal audit tool is essential to act as a structured guide for auditing newborn unit care in LMICs. The quality of audit process guide is a useful method of ensuring high quality audits in health facilities.
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Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya.
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
- Pumwani Maternity Hospital, Nairobi, Kenya.
| | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Osborne V, Lane S, Shakir SAW. The Role of the Contextual Cohort to Resolve Some Challenges and Limitations of Comparisons in Pharmacoepidemiology. Drug Saf 2021; 44:835-841. [PMID: 33961212 PMCID: PMC8279980 DOI: 10.1007/s40264-021-01074-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/12/2022]
Abstract
In pharmacoepidemiology, comparison studies can provide a useful estimate of the level of increased or decreased risk of specific events with a medication (through a measure of effect). A key focus of pharmacoepidemiological studies is the safety and effectiveness of medicines in their real-world use, and adequate comparisons of effect estimates are critical. However, consideration of guidelines, pharmacoeconomic assessments, and policies for reimbursement have made comparisons in pharmacoepidemiological studies far more difficult to conduct in recent years. Where certain subject characteristics influence the probability of being exposed to a treatment, this can introduce issues of selection bias and confounding. Methodologies are available to minimise selection bias (through case-only and randomised study designs) and deal with confounding (such as regression modelling or propensity score matching methods), however these each have their own limitations. Where prescribing guidelines are present, conducting comparisons in pharmacoepidemiology produces many challenges and not all of these can be easily overcome. Patient channelling can be more frequent with adherence to clinical guidelines compared with when prescribing decisions by doctors are based predominantly on their clinical judgement. Use of a contextual cohort could be considered as an option to characterise the adoption of new medications into clinical practice and describe the prevalence of clinical characteristics and risk factors in the two cohorts, rather than compare event rates and produce an estimate of effect.
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Affiliation(s)
- Vicki Osborne
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK. .,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK.
| | - Samantha Lane
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK.,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Saad A W Shakir
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK.,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Houle B, Kabudula CW, Stein A, Gareta D, Herbst K, Clark SJ. Linking the timing of a mother's and child's death: Comparative evidence from two rural South African population-based surveillance studies, 2000-2015. PLoS One 2021; 16:e0246671. [PMID: 33556118 PMCID: PMC7869981 DOI: 10.1371/journal.pone.0246671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The effect of the period before a mother's death on child survival has been assessed in only a few studies. We conducted a comparative investigation of the effect of the timing of a mother's death on child survival up to age five years in rural South Africa. METHODS We used discrete time survival analysis on data from two HIV-endemic population surveillance sites (2000-2015) to estimate a child's risk of dying before and after their mother's death. We tested if this relationship varied between sites and by availability of antiretroviral therapy (ART). We assessed if related adults in the household altered the effect of a mother's death on child survival. FINDINGS 3,618 children died from 2000-2015. The probability of a child dying began to increase in the 7-11 months prior to the mother's death and increased markedly in the 3 months before (2000-2003 relative risk = 22.2, 95% CI = 14.2-34.6) and 3 months following her death (2000-2003 RR = 20.1; CI = 10.3-39.4). This increased risk pattern was evident at both sites. The pattern attenuated with ART availability but remained even with availability at both sites. The father and maternal grandmother in the household lowered children's mortality risk independent of the association between timing of mother and child mortality. CONCLUSIONS The persistence of elevated mortality risk both before and after the mother's death for children of different ages suggests that absence of maternal care and abrupt breastfeeding cessation might be crucial risk factors. Formative research is needed to understand the circumstances for children when a mother is very ill or dies, and behavioral and other risk factors that increase both the mother and child's risk of dying. Identifying families when a mother is very ill and implementing training and support strategies for other members of the household are urgently needed to reduce preventable child mortality.
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Affiliation(s)
- Brian Houle
- School of Demography, The Australian National University, Canberra, Australia
- Faculty of Health Sciences, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- CU Population Center, Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, United States of America
| | - Chodziwadziwa W. Kabudula
- Faculty of Health Sciences, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Stein
- Faculty of Health Sciences, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Samuel J. Clark
- Faculty of Health Sciences, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- CU Population Center, Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, United States of America
- Department of Sociology, The Ohio State University, Columbus, Ohio, United States of America
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Kalolo A, Gautier L, Radermacher R, Srivastava S, Meshack M, De Allegri M. Factors influencing variation in implementation outcomes of the redesigned community health fund in the Dodoma region of Tanzania: a mixed-methods study. BMC Public Health 2021; 21:1. [PMID: 33388037 PMCID: PMC7777388 DOI: 10.1186/s12889-020-10013-y] [Citation(s) in RCA: 341] [Impact Index Per Article: 113.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 12/06/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction Micro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania. Methods We adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data. Results A review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills. At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04). Conclusion The study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-10013-y.
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Affiliation(s)
- Albino Kalolo
- Department of Public Health, St. Francis University College of Health and Allied Sciences, P.O. Box 175, Ifakara, Tanzania. .,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany.
| | - Lara Gautier
- Department of Sociology, Faculty of Arts, McGill University, Montreal, Canada
| | - Ralf Radermacher
- Deutsche Gesellschaft für Internationale Zusammenarbeit, 10/319, Mtendere Drive, Lilongwe, Malawi
| | - Siddharth Srivastava
- Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box CH-4002, Basel, Switzerland.,University of Basel, Petersplatz 1, P. O. Box 4001, Basel, Switzerland
| | - Menoris Meshack
- Health Promotion and System Strengthening (HPSS) Project, P.O Box 29, Dodoma, Tanzania
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
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Promoting pediatric oncology nursing excellence in sub-Saharan Africa using project ECHO. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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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.
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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
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Laurenzi CA, Skeen S, Coetzee BJ, Gordon S, Notholi V, Tomlinson M. How do pregnant women and new mothers navigate and respond to challenges in accessing health care? Perspectives from rural South Africa. Soc Sci Med 2020; 258:113100. [PMID: 32534304 DOI: 10.1016/j.socscimed.2020.113100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/13/2020] [Accepted: 05/30/2020] [Indexed: 11/30/2022]
Abstract
Women in low- and middle-income countries and in contexts characterized by inequality face various interpersonal and structural barriers when accessing formal maternal and child health (MCH) services. These barriers persist even in contexts where programs to increase access to services, such as community health worker (CHW) interventions, have been implemented. However, while barriers to accessing care have been extensively documented, less is known about the diverse ways that women respond to, and navigate, these situations. This study explores strategies pregnant women and new mothers use to navigate and respond to health care barriers in a rural district in the Eastern Cape, South Africa. Twenty-six pregnant or recently delivered clients of the Enable Mentor Mother program were interviewed about their experiences of accessing formal MCH services. Interviews were conducted between February-March 2018 by an experienced isiXhosa-speaking research assistant, translated and transcribed into English, with transcripts coded and organized by themes using ATLAS.ti software. Facing resource shortages, inconsistent communication, and long travel times to clinics, participants employed diverse, innovative strategies to navigate interpersonal and structural barriers to care. While some participants chose to respond to barriers more passively-citing endurance and acceptance as practices of health system engagement-those participants who focused more on active responses tended to leverage their education, existing relationships, and available community resources to overcome barriers. Nevertheless, most participants described feelings of frustration and dejection. While CHW interventions may alleviate some of the burdens facing fragile health care systems in these contexts, these programs still rely on an underlying infrastructure of care that primary health care clinics and hospitals should be providing. Future programming should work in tandem with formal health systems and should support staff to improve quality of care provided to pregnant women, new mothers, and their infants to prioritize their health at a time of vulnerability.
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Affiliation(s)
- Christina A Laurenzi
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa; Department of Psychology, Willcocks Building, Stellenbosch University, Stellenbosch, Western Cape, 7600, South Africa.
| | - Sarah Skeen
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa
| | - Bronwyne J Coetzee
- Department of Psychology, Willcocks Building, Stellenbosch University, Stellenbosch, Western Cape, 7600, South Africa
| | - Sarah Gordon
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa
| | - Vuyolwethu Notholi
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, 4009 Education Building, Faculty of Medical and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Western Cape, 7505, South Africa; School of Nursing and Midwifery, Queens University, Medical Biology Centre, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, United Kingdom
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13
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Tosif S, Jatobatu A, Maepioh A, Gray A, Gilbert K, Hodgson J, Duke T. Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study. Am J Trop Med Hyg 2020; 102:667-675. [PMID: 31971147 PMCID: PMC7056423 DOI: 10.4269/ajtmh.19-0631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/24/2019] [Indexed: 11/07/2022] Open
Abstract
Multifaceted interventions are important in improving neonatal quality of care and health outcomes. This study describes the implementation of an intervention to improve the quality of newborn care in Solomon Islands, a small island developing state and lower middle-income country in the Western Pacific. Inputs included training, equipment provision, and healthcare system organizational changes. For evaluation, we used a mixed-methods design, using quantitative (audits of health facility equipment, structure, and organization) and qualitative (semi-structured interviews and focused group discussions with healthcare workers) methods. Participants highlighted the practical, interactive, coaching style of training and its short duration as positive features in establishing skills. Training had indirect impacts through improving culture of the workplace, and the evaluation provided a valuable opportunity for reflection of the implementation process for healthcare workers. Facility limitations from equipment deficits and poor condition of clinical areas had implications by limiting the provision of quality care, as well as contributing to healthcare workers feeling undervalued. Resuscitation of a nonbreathing baby was a stressful experience for many health workers, compounded by geographic isolation and feeling unsupported. Our findings highlight the importance of training methodology, impact from structural limitations, and experience of resuscitation for the healthcare worker. Attention to these factors may help the design and implementation of newborn care programs in similar contexts.
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Affiliation(s)
- Shidan Tosif
- Centre for International Child Health, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, University of Melbourne, Parkville VIC, Australia
| | - Anna Jatobatu
- Reproductive and Child Health Department, Ministry of Health and Medical Services, Honiara, Solomon Islands
| | - Anita Maepioh
- Department of Obstetrics and Gynaecology, National Referral Hospital, Honiara, Solomon Islands
| | - Amy Gray
- Centre for International Child Health, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, University of Melbourne, Parkville VIC, Australia
| | - Katherine Gilbert
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Parkville VIC, Australia
| | - Jan Hodgson
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia
| | - Trevor Duke
- Centre for International Child Health, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, University of Melbourne, Parkville VIC, Australia
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Laurenzi CA, Gordon S, Skeen S, Coetzee BJ, Bishop J, Chademana E, Tomlinson M. The home visit communication skills inventory: Piloting a tool to measure community health worker fidelity to training in rural South Africa. Res Nurs Health 2019; 43:122-133. [PMID: 31793678 DOI: 10.1002/nur.22000] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/20/2019] [Indexed: 11/12/2022]
Abstract
Community-based home visiting programs using community health workers (CHWs) have become popular modes of delivering health care services, especially in settings where health workers are overburdened and resources are limited. Yet, little is known about the processes that shape effective implementation in low-resource settings, and whether these processes adhere to home visitors' training. This study used the newly-developed Home Visit Communication Skills Inventory (HCSI) to explore the delivery of a CHW program in rural South Africa. Routine home visits from CHWs to their maternal care clients were audio-recorded with consent, and later transcribed and translated into English. The HCSI, devised and piloted using existing frameworks and program-specific training components, consisted of 21 items covering domains related to active listening, active delivery, and active connecting, and was used to score English transcripts of the home visits. The HCSI was used to generate general frequencies and aggregate scores for each CHW. Eighty-four home visits by 14 CHWs showed a diverse application of communication skills. Active listening and active delivery were common, with fewer instances of active connecting observed. Practices disaggregated by CHW showcased varying strengths by an individual. In reviewing visit characteristics, longer average visit duration was significantly correlated with the presence of multiple types of active connecting skills. While technical skills were widely observed, fewer CHWs engaged in more complex "connecting" skills. The HCSI is a feasible, low-cost, and practical way to describe home visit fidelity among CHWs. Audio-based checklists can be used to describe fidelity to a model in the absence of additional supervisory resources.
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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 Gordon
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, 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
| | - Julia Bishop
- One to One Africa Children's Fund, Cape Town, South Africa
| | - Emma Chademana
- 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, UK
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15
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Ingram M, Denman CA, Cornejo-Vucovich E, Castro-Vasquez MDC, Aceves B, Ocejo AG, de Zapien JG, Rosales C. The Meta Salud Diabetes Implementation Study: Qualitative Methods to Assess Integration of a Health Promotion Intervention Into Primary Care to Reduce CVD Risk Among an Underserved Population With Diabetes in Sonora, Mexico. Front Public Health 2019; 7:347. [PMID: 31803710 PMCID: PMC6874016 DOI: 10.3389/fpubh.2019.00347] [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: 06/30/2019] [Accepted: 11/01/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Within health promotion research, there is a need to assess strategies for integration and scale up in primary care settings. Hybrid interventions that combine clinical effectiveness trials with implementation studies can elicit important contextual information on facilitators and barriers to integration within a health care system. This article describes lessons learned in developing and implementing a qualitative study of a cluster-randomized controlled trial (RCT) to reduce cardiovascular disease (CVD) among people with diabetes in Sonora, Mexico, 2015–2019. Methods:The research team worked cooperatively with health center personnel from 12 Centers that implemented the intervention. The study used observations, stakeholder meetings, case studies, staff interviews and decision maker interviews to explore issues such as staff capacity, authority, workflow, space, and conflicting priorities, as well as patients' response to the program within the clinical context and their immediate social environments. Applying a multi-layered contextual framework, two members of the research team coded an initial sample of the data to establish inclusion criteria for each contextual factor. The full team finalized definitions and identified sub nodes for the final codebook. Results: Characteristics of management, staffing, and the local environment were identified as essential to integration and eventual adoption and scale up across the health system. Issues included absence of standardized training and capacity building in chronic disease and health promotion, inadequate medical supplies, a need for program monitoring and feedback, and lack of interdisciplinary support for center staff. Lack of institutional support stemming from a curative vs. preventive approach to care was a barrier for health promotion efforts. Evolving analysis, interpretation, and discussion resulted in modifications of flexible aspects of the intervention to realities of the health center environment. Conclusion: This study illustrates that a robust and comprehensive qualitative study of contextual factors across a social ecological spectrum is critical to elucidating factors that will promote future adoption and scale up of health promotion programs in primary care. Application of conceptual frameworks and health behavior theory facilitates identification of facilitators and barriers across contexts. Trial registration:www.ClinicalTrials.gov, identifier: NCT02804698 Registered on June 17, 2016.
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Affiliation(s)
- Maia Ingram
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson, AZ, United States
| | - Catalina A Denman
- Center for Health and Society Studies, El Colegio de Sonora, Hermosillo, Mexico
| | | | | | - Benjamin Aceves
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson, AZ, United States
| | - Abraham Garcia Ocejo
- Department of Epidemiology, Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson, AZ, United States
| | - Jill Guernsey de Zapien
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson, AZ, United States
| | - Cecilia Rosales
- Division of Public Health Practice and Translational Research, Mel and Enid Zuckerman College of Public Health University of Arizona, Tucson, AZ, United States
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Mocumbi S, McKee K, Munguambe K, Chiau R, Högberg U, Hanson C, Wallin L, Sevene E, Bergström A. Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique. Glob Health Action 2019; 11:1532631. [PMID: 30387378 PMCID: PMC6225433 DOI: 10.1080/16549716.2018.1532631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence. Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique. Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique. Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed. Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.
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Affiliation(s)
- Sibone Mocumbi
- a Department of Obstetrics and Gynaecology, Faculty of Medicine , Universidade Eduardo Mondlane (UEM) , Maputo , Mozambique.,b Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden
| | - Kevin McKee
- c School of Education, Health and Social Studies , Dalarna University , Falun , Sweden
| | - Khátia Munguambe
- d Department of Public Health , Faculty of Medicine, Universidade Eduardo Mondlane (UEM) , Maputo , Mozambique.,e Centro de Investigação em Saúde de Manhiça (CISM) , Manhiça , Mozambique
| | - Rogério Chiau
- e Centro de Investigação em Saúde de Manhiça (CISM) , Manhiça , Mozambique
| | - Ulf Högberg
- b Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden
| | - Claudia Hanson
- f Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,g Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK
| | - Lars Wallin
- c School of Education, Health and Social Studies , Dalarna University , Falun , Sweden.,h Department of Neurobiology, Care Sciences and Society, Division of Nursing , Karolinska Institutet , Stockholm , Sweden.,i Department of Health and Care Sciences , The Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Esperança Sevene
- e Centro de Investigação em Saúde de Manhiça (CISM) , Manhiça , Mozambique.,j Department of Physiological Science, Clinical Pharmacology , Faculty of Medicine, Universidade Eduardo Mondlane (UEM) , Maputo , Mozambique
| | - Anna Bergström
- b Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden.,k Institute for Global Health , University College London , London , UK
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Vousden N, Lawley E, Seed PT, Gidiri MF, Charantimath U, Makonyola G, Brown A, Yadeta L, Best R, Chinkoyo S, Vwalika B, Nakimuli A, Ditai J, Greene G, Chappell LC, Sandall J, Shennan AH. Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings. Implement Sci 2019; 14:38. [PMID: 30999963 PMCID: PMC6471783 DOI: 10.1186/s13012-019-0885-3] [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: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/02/2022] Open
Abstract
Background Interventions aimed at reducing maternal mortality are increasingly complex. Understanding how complex interventions are delivered, to whom, and how they work is key in ensuring their rapid scale-up. We delivered a vital signs triage intervention into routine maternity care in eight low- and middle-income countries with the aim of reducing a composite outcome of morbidity and mortality. This was a pragmatic, hybrid effectiveness-implementation stepped-wedge randomised controlled trial. In this study, we present the results of the mixed-methods process evaluation. The aim was to describe implementation and local context and integrate results to determine whether differences in the effect of the intervention across sites could be explained. Methods The duration and content of implementation, uptake of the intervention and its impact on clinical management were recorded. These were integrated with interviews (n = 36) and focus groups (n = 19) at 3 months and 6–9 months after implementation. In order to determine the effect of implementation on effectiveness, measures were ranked and averaged across implementation domains to create a composite implementation strength score and then correlated with the primary outcome. Results Overall, 61.1% (n = 2747) of health care providers were trained in the intervention (range 16.5% to 89.2%) over a mean of 10.8 days. Uptake and acceptability of the intervention was good. All clusters demonstrated improved availability of vital signs equipment. There was an increase in the proportion of women having their blood pressure measured in pregnancy following the intervention (79.2% vs. 97.6%; OR 1.30 (1.29–1.31)) and no significant change in referral rates (3.7% vs. 4.4% OR 0.89; (0.39–2.05)). Availability of resources and acceptable, effective referral systems influenced health care provider interaction with the intervention. There was no correlation between process measures within or between domains, or between the composite score and the primary outcome. Conclusions This process evaluation has successfully described the quantity and quality of implementation. Variation in implementation and context did not explain differences in the effectiveness of the intervention on maternal mortality and morbidity. We suggest future trials should prioritise in-depth evaluation of local context and clinical pathways. Trial registration Trial registration: ISRCTN41244132. Registered on 2 Feb 2016 Electronic supplementary material The online version of this article (10.1186/s13012-019-0885-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK.
| | - Elodie Lawley
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Umesh Charantimath
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, 590010, India
| | - Grace Makonyola
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG, UK
| | - Adrian Brown
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG, UK
| | - Lomi Yadeta
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, BN1 3XG, UK
| | - Rebecca Best
- Welbodi Partnership, Ola During Childrens Hospital, Freetown, Sierra Leone
| | - Sebastian Chinkoyo
- Department of Obstetrics and Gynaecology, Ndola Teaching Hospital, Ndola, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia, Lusaka, Zambia
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, Mulago Hospital, Makerere University, Kampala, Uganda
| | - James Ditai
- Sanyu Africa Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Grace Greene
- Hope Health Action, Hopital Convention Baptiste d'Haiti, Cap Haitien, Haiti
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
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Circumstances of child deaths in Mali and Uganda: a community-based confidential enquiry. LANCET GLOBAL HEALTH 2018; 6:e691-e702. [PMID: 29773123 DOI: 10.1016/s2214-109x(18)30215-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/26/2018] [Accepted: 03/26/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Interventions to reduce child deaths in Africa have often underachieved, causing the Millennium Development Goal targets to be missed. We assessed whether a community enquiry into the circumstances of death could improve intervention effectiveness by identifying local avoidable factors and explaining implementation failures. METHODS Deaths of children younger than 5 years were ascertained by community informants in two districts in Mali (762 deaths) and three districts in Uganda (442 deaths) in 2011-15. Deaths were investigated by interviewing parents and health workers. Investigation findings were reviewed by a panel of local health-care workers and community representatives, who formulated recommendations to address avoidable factors and, subsequently, oversaw their implementation. FINDINGS At least one avoidable factor was identified in 97% (95% CI 96-98, 737 of 756) of deaths in children younger than 5 years in Mali and 95% (93-97, 389 of 409) in Uganda. Suboptimal newborn care was a factor in 76% (146 of 194) of neonatal deaths in Mali and 64% (134 of 194) in Uganda. The most frequent avoidable factor in postneonatal deaths was inadequate child protection (mainly child neglect) in Uganda (29%, 63 of 215) and malnutrition in Mali (22%, 124 of 562). 84% (618 of 736 in Mali, 328 of 391 in Uganda) of families had consulted a health-care provider for the fatal illness, but the quality of care was often inadequate. Even in official primary care clinics, danger signs were often missed (43% of cases in Mali [135 of 396], 39% in Uganda [30 of 78]), essential treatment was not given (39% in Mali [154 of 396], 35% in Uganda [27 of 78]), and patients who were seriously ill were not referred to a hospital in time (51% in Mali [202 of 396], 45% in Uganda [35 of 78]). Local recommendations focused on quality of care in health-care facilities and on community issues influencing treatment-seeking behaviour. INTERPRETATION Local investigation and review of circumstances of death of children in sub-Saharan Africa is likely to lead to more effective interventions than simple consideration of the biomedical causes of death. This approach discerned local public health priorities and implementable solutions to address the avoidable factors identified. FUNDING European Union's 7th Framework Programme for research and technological development.
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Baker U, Petro A, Marchant T, Peterson S, Manzi F, Bergström A, Hanson C. Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework. PLoS One 2018; 13:e0209092. [PMID: 30566511 PMCID: PMC6300247 DOI: 10.1371/journal.pone.0209092] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Quality Improvement (QI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect. Materials and methods A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARIHS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes. Results Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention’s comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge. Conclusion Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.
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Affiliation(s)
- Ulrika Baker
- Department of Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden
- * E-mail: ,
| | - Arafumin Petro
- Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania
| | - Tanya Marchant
- Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
| | - Stefan Peterson
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
- Makerere School of Public Health, Kampala, Uganda
- UNICEF, Health Section, Programme Division, New York, United States of America
| | - Fatuma Manzi
- Ifakara Health Institute, Health Systems, Impact Evaluation and Policy (HSIEP), Dar es Salaam, Tanzania
| | - Anna Bergström
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
- Institute for Global Health, University College London, London, United Kingdom
| | - Claudia Hanson
- Department of Public Health Sciences, Global Health—Health Systems and Policy Research, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom
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20
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Chesoli RN, Schuster RC, Okelo S, Omotayo MO. Strengthening Care Delivery in Primary Care Facilities: Perspectives of Facility Managers on the Immunization Program in Kenya. Int J Health Policy Manag 2018; 7:1130-1137. [PMID: 30709088 PMCID: PMC6358659 DOI: 10.15171/ijhpm.2018.83] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 08/25/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as 'street-level bureaucrats,' their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery. METHODS We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision. RESULTS The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness. CONCLUSION Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya.
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Affiliation(s)
| | | | | | - Moshood O Omotayo
- State University of New York at Buffalo, Buffalo, NY, USA.,Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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21
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Wachira J, Genberg B, Kafu C, Koech B, Akinyi J, Owino RK, Laws MB, Wilson IB, Braitstein P. The Perspective of HIV Providers in Western Kenya on Provider-Patient Relationships. JOURNAL OF HEALTH COMMUNICATION 2018; 23:591-596. [PMID: 29979930 PMCID: PMC6094379 DOI: 10.1080/10810730.2018.1493061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Enhancing effective adherence dialogue with HIV patients in an environment that promotes good provider-patient relationships, is key to optimizing the benefits of antiretroviral therapy (ART). The study examines the perspectives of HIV providers in western Kenya on provider-patient relationships. Sixty healthcare providers were sampled using convenience sampling methods from three Academic Model for Providing Access to Healthcare (AMPATH) sites (one urban and two rural). In-depth interviews conducted in either Swahili or English were audio recorded, transcribed, and translated into English. Content analysis was performed after thematic coding. Providers perceived that they had good relationships with most patients, and tended to identify negative patient attributes as the source of poor provider-patient relationships. Providers preferred patients who adhered to treatment guidelines. They did not like patients who challenged their authority, and did not see it as their responsibility to find more effective ways of interacting with patients who they found difficult. Structural barriers to collaborative physician-patient relationships included noncontinuity of relationships, lack of specific appointment times, high provider-patient ratio, and management of provider fatigue and job dissatisfaction. There is need for HIV care programs to identify culturally appropriate interventions to enhance better provider-patient relationship.
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Affiliation(s)
- Juddy Wachira
- a School of Medicine , Moi University , Eldoret , Kenya
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Becky Genberg
- c Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| | - Catherine Kafu
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Beatrice Koech
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Jacqueline Akinyi
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Regina K Owino
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Michael Barton Laws
- d Department of Health Services, Policy & Practice , Brown University , Providence, RI, USA
| | - Ira B Wilson
- d Department of Health Services, Policy & Practice , Brown University , Providence, RI, USA
| | - Paula Braitstein
- e Dalla Lana School of Public Health , University of Toronto , Toronto, Ontario , Canada
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22
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O’Donovan J, O’Donovan C, Kuhn I, Sachs SE, Winters N. Ongoing training of community health workers in low-income andmiddle-income countries: a systematic scoping review of the literature. BMJ Open 2018; 8:e021467. [PMID: 29705769 PMCID: PMC5931295 DOI: 10.1136/bmjopen-2017-021467] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/06/2018] [Accepted: 04/10/2018] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Understanding the current landscape of ongoing training for community health workers (CHWs) in low-income and middle-income countries (LMICs) is important both for organisations responsible for their training, as well as researchers and policy makers. This scoping review explores this under-researched area by mapping the current delivery implementation and evaluation of ongoing training provision for CHWs in LMICs. DESIGN Systematic scoping review. DATA SOURCES MEDLINE, Embase, AMED, Global Health, Web of Science, Scopus, ASSIA, LILACS, BEI and ERIC. STUDY SELECTION Original studies focusing on the provision of ongoing training for CHWs working in a country defined as low income and middle income according to World Bank Group 2012 classification of economies. RESULTS The scoping review found 35 original studies that met the inclusion criteria. Ongoing training activities for CHWs were described as supervision (n=19), inservice or refresher training (n=13) or a mixture of both (n=3). Although the majority of studies emphasised the importance of providing ongoing training, several studies reported no impact of ongoing training on performance indicators. The majority of ongoing training was delivered inperson; however, four studies reported the use of mobile technologies to support training delivery. The outcomes from ongoing training activities were measured and reported in different ways, including changes in behaviour, attitudes and practice measured in a quantitative manner (n=16), knowledge and skills (n=6), qualitative assessments (n=5) or a mixed methods approach combining one of the aforementioned modalities (n=8). CONCLUSIONS This scoping review highlights the diverse range of ongoing training for CHWs in LMICs. Given the expansion of CHW programmes globally, more attention should be given to the design, delivery, monitoring and sustainability of ongoing training from a health systems strengthening perspective.
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Affiliation(s)
| | | | - Isla Kuhn
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
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23
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Wachira J, Genberg B, Kafu C, Braitstein P, Laws MB, Wilson IB. Experiences and expectations of patients living with HIV on their engagement with care in Western Kenya. Patient Prefer Adherence 2018; 12:1393-1400. [PMID: 30122904 PMCID: PMC6078080 DOI: 10.2147/ppa.s168664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE In resource-limited HIV care settings, effective and innovative interventions that respond to the existing challenges along the HIV care continuum are urgently needed to realize the benefits of antiretroviral therapy (ART). Initiating effective ART adherence dialog in an environment that promotes patient engagement in care is key. It is therefore critical to enhance our understanding about how patients living with HIV in these regions conceptualize and experience patient engagement. This study explores HIV patients' perceptions, experiences and expectations of their engagement in care. MATERIALS AND METHODS We sampled 86 patients from three Academic Model for Providing Access to Healthcare (AMPATHplus) sites, one urban and two rural. We conducted 24 in-depth interviews and eight focus group discussions in either Swahili or English. Audio recordings of the interviews were transcribed, and then translated into English. We performed content analysis after thematic coding. RESULTS Patients living with HIV in Kenya desire active engagement with care. However, their engagement was inconsistent and varied depending on the provider. Patients had a sense of how provider's interpersonal behaviors influenced their level of engagement. These included various aspects of provider-patient communication and relationship dynamics. Patients also highlighted relational boundaries that influenced the level and kind of information they shared with their providers. Aspects of their psychological, social or economic wellbeing were often viewed as personal and not discussed with their clinicians. Patients identified factors that would promote or impede their engagement with care including those related to patients themselves, providers, and the healthcare system. CONCLUSION Patients living with HIV desired more active engagement in their care. In addition, they desired clinicians to engage in more social behaviors to promote patient engagement. To address existing patient engagement barriers, HIV care systems in the region should apply contextualized patient-centered interventions.
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Affiliation(s)
- Juddy Wachira
- Department of Behavioral Sciences, School of Medicine, Moi University, Eldoret, Kenya,
- Department of Epidemiology, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA,
| | - Becky Genberg
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Catherine Kafu
- Department of Epidemiology, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA,
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Michael Barton Laws
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Ira B Wilson
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
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24
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Edwards N, Kahwa E, Hoogeveen K. Results of an Integrative Analysis: A Call for Contextualizing HIV and AIDS Clinical Practice Guidelines to Support Evidence-Based Practice. Worldviews Evid Based Nurs 2017; 14:492-498. [PMID: 28755393 PMCID: PMC5763348 DOI: 10.1111/wvn.12247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 11/30/2022]
Abstract
Background Practice guidelines aim to improve the standard of care for people living with HIV/AIDS. Successfully implementing guidelines requires tailoring them to populations served and to social and organizational influences on care. Aims To examine dimensions of context, which nurses and midwives described as having a significant impact on their care of patients living with HIV/AIDS in Kenya, Uganda, South Africa, and Jamaica and to determine whether HIV/AIDS guidelines include adaptations congruent with these dimensions of context. Methods Two sets of data were used. The first came from a qualitative study. In‐depth interviews were conducted with purposively selected nurses, midwives, and nurse managers from 21 districts in four study countries. A coding framework was iteratively developed and themes inductively identified. Context dimensions were derived from these themes. A second data set of published guidelines for HIV/AIDS care was then assembled. Guidelines were identified through Google and PubMed searches. Using a deductive integrative analysis approach, text related to context dimensions was extracted from guidelines and categorized into problem and strategy statements. Results Ninety‐six individuals participated in qualitative interviews. Four discrete dimensions of context were identified: health workforce adequacy, workplace exposure risk, workplace consequences for nurses living with HIV/AIDS, and the intersection of work and family life. Guidelines most often acknowledged health human resource constraints and presented mitigation strategies to offset them, and least often discussed workplace consequences and the intersections of family and work life. Linking Evidence to Action Guidelines should more consistently acknowledge diverse implementation contexts, propose how recommendations can be adapted to these realities, and suggest what role frontline healthcare providers have in realizing the structural changes necessary for healthier work environments and better patient care. Guideline recommendations should include more explicit advice on adapting their recommendations to different care conditions.
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Affiliation(s)
- Nancy Edwards
- Professor, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Eulalia Kahwa
- Senior Lecturer, The UWI School of Nursing, University of the West Indies, Kingston, Jamaica
| | - Katie Hoogeveen
- Research Coordinator, School of Nursing, University of Ottawa, Ottawa, Canada
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Johnson BT, Cromley EK, Marrouch N. Spatiotemporal meta-analysis: reviewing health psychology phenomena over space and time. Health Psychol Rev 2017. [PMID: 28625102 DOI: 10.1080/17437199.2017.1343679] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Individual studies of health psychology are samples taken in particular places at particular times. The results of such studies manifest multiple processes, including those associated with individual, sample, intervention, and study design characteristics. Although extant meta-analyses of health phenomena have routinely considered these factors to explain heterogeneity, they have tended to neglect the environments where studies are conducted, which is ironic, as health phenomena cluster in space and times (e.g., epidemics). The settings in which study participants live, work, and recreate can be characterised by such environmental factors such as disease, weather, local and broad economic trends, the level of stigmatisation of minority groups, and allostatic load due to all causes. We introduce spatiotemporal meta-analysis, designed to address heterogeneity in study environments. We list potential challenges in developing spatiotemporal meta-analyses, and discuss future directions for this form of systematic reviewing methodology. Logically, to the extent that relevant spatiotemporal information on environmental conditions is available and varies widely, it can help to explain variability in study results that is not explained by individual, sample, study, or intervention features.
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Affiliation(s)
- Blair T Johnson
- a Department of Psychological Sciences and Institute for Collaboration on Health, Intervention, and Policy , University of Connecticut , Storrs , CT , USA.,c Department of Psychological Sciences , University of Connecticut , Storrs , CT , USA
| | - Ellen K Cromley
- b School of Medicine, University of Connecticut , Storrs , CT , USA
| | - Natasza Marrouch
- a Department of Psychological Sciences and Institute for Collaboration on Health, Intervention, and Policy , University of Connecticut , Storrs , CT , USA.,c Department of Psychological Sciences , University of Connecticut , Storrs , CT , USA
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Variation matters and should be included in health care research for comparison of outcomes. Prim Health Care Res Dev 2016; 18:183-187. [DOI: 10.1017/s1463423616000438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background
Health care is provided under the conditions in which people live and under the rules and regulations of a prevailing health system. As a consequence, ‘local’ circumstances are an important determinant of the actual care that can be provided and its effects on the health of individuals and populations. This plays in particular, but not exclusively, a role in community-based primary health care. Although this is generally accepted, there is little insight in the impact of the setting and context in which health care is provided on the outcome of care.
Aim
This paper argues the case to use this natural variation within and between countries as an opportunity to be used as a form of natural experiment in health research.
Arguments
We argue that analysing and comparing outcomes across settings, that is comparative outcomes of interventions that have been performed under different health care conditions will improve the understanding of how the real-life setting in which health care is provided – including the health system, the socio-economic circumstances and prevailing cultural values – do determine outcome of care.
Recommendations
To facilitate comparison of research findings across health systems and different socio-economic and cultural contexts, we recommend a more detailed reporting of the conditions and circumstances under which health research has been performed. A set of core variables is proposed for studies in primary health care.
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