The impact of health worker absenteeism on patient health care seeking behavior, testing and treatment: A longitudinal analysis in Uganda

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Global Burden of Absenteeism Related to COVID-19 Vaccine Side Effects Among Healthcare Workers: A Systematic Review and Meta-Analysis

Background: A rise in absenteeism among healthcare workers (HCWs) was recorded during the COVID-19 pandemic, mostly attributed to SARS-CoV-2 infections. However, evidence suggests that COVID-19 vaccine-related side effects may have also contributed to absenteeism during this period. This study aimed to synthesize the evidence on the prevalence of absenteeism related to COVID-19 vaccine side effects among HCWs. Methods: The inclusion criteria for this review were original quantitative studies of any design, written in English, that addressed absenteeism related to the side effects of COVID-19 vaccines among HCWs. Four databases (PubMed, Scopus, Embase, and the Web of Science) were searched for eligible articles on 7 June 2024. The risk of bias was assessed using the Newcastle-Ottawa scale. Narrative synthesis and a meta-analysis were used to synthesize the evidence. Results: Nineteen observational studies with 96,786 participants were included. The pooled prevalence of absenteeism related to COVID-19 vaccine side effects was 17% (95% CI: 13-20%), while 83% (95% CI: 80-87%) of the vaccination events did not lead in any absenteeism. Study design, sex, vaccination dose, region, and vaccine type were identified as significant sources of heterogeneity. Conclusions: A non-negligible proportion of HCWs were absent from work after reporting side effects of the COVID-19 vaccine. Various demographic factors should be considered in future vaccination schedules for HCWs to potentially decrease the burden of absenteeism related to vaccine side effects. As most studies included self-reported questionnaire data, our results may be limited due to a recall bias. Other: The protocol of the study was preregistered in the PROSPERO database (CRD42024552517).

Exploring health worker absenteeism at public healthcare facilities in Chhattisgarh, India

AIM

This study aims to assess the health worker absenteeism and factors associated with it in a high-focus district in Chhattisgarh, India.

BACKGROUND

Human resources for health are among the key foundations to build resilient healthcare systems. Chhattisgarh is a high-focus Indian state with a severe shortage of health care workers, and absenteeism further aggravates the shortage.

METHODS

This study was conducted as a mixed-methods study employing sequential explanatory design. Absenteeism was defined as the absence of health worker in the designated position without a formal leave or official reason in two different unannounced visits. A facility survey across all the public healthcare facilities in Jashpur district, Chhattisgarh, was conducted through random, unannounced visits employing a checklist developed based on Indian Public Health Standards. Twelve participants were purposively sampled and interviewed from healthcare facilities to explore factors associated with absenteeism. Survey data were analysed descriptively, and thematic analysis was employed to analyse qualitative interviews.

FINDINGS

Among all the positions filled at primary health centre level (n = 339), close to 8% (n = 27) were absent, whereas among the positions filled at community health centre level (n = 285), only 1.14% (n = 4) were absent. Absenteeism was not found in the district hospital. Qualitative interviews reveal that macro-level (geographical location and lack of connectivity), meso-level (lack of equipment and amenities, makeshift health facilities, doctor shortage, and poor patient turnover), and micro-level (unmet expectations) factors contribute to health worker absenteeism.

CONCLUSION

Health worker absenteeism was more at PHC level. Systemic challenges, human resource shortages, and infrastructural shortcomings contributed to health worker absenteeism.

Clinical officers in Uganda: Training and workforce role

ABSTRACT

The clinical role of a clinical officer in Uganda is very similar to that of a physician associate/assistant in the United States. This article describes the qualifications and workforce role of clinical officers in Uganda, as well as their use in two primary care programs that provide effective, low-cost medical care to a growing population with an increasing burden of chronic disease.

Factors Related to Client Satisfaction with Community Based Health Insurance Services During COVID-19 Pandemic in Central Uganda: A Mixed Methods Healthcare Facility Based Study

Background

During the COVID-19 lockdowns, healthcare services were disrupted and community-based health insurance (CBHI) schemes could not operate efficiently. This study assessed the level of client satisfaction with CBHI schemes, associated factors, and service provider perspectives in central Uganda.

Methods

This was an explanatory sequential mixed-methods (quantitative - qualitative) study that was conducted between March and September 2021. In the first phase, a cross-sectional study among the 365 clients of the CBHI schemes who were aged ≥18 years old. The participants were recruited consecutively as they reported to the healthcare facility. Quantitative data were collected at patient exit using a piloted semi-structured interviewer-administered questionnaire. In the second phase, qualitative data were collected through 11 key informant interviews. These data were analyzed using a deductive thematic analysis approach. Modified Poisson regression was used to assess factors associated with client satisfaction and a p-value ≤0.05 at a 95% confidence interval was considered to be statistically significant.

Findings

Of the total number of participants, 38.9% (142/365) were "satisfied" with the CBHI services. Less satisfaction was associated with secondary level of education or above (adjPR = 0.55, 95% CI: 0.36-0.85, P=.007); residing beyond 16 kilometers from the healthcare facility (adjPR = 0.68, 95% CI: 0.41-0.95, P=.014); staying on the scheme for over 3 years (adjPR = 0.71, 95% CI: 0.51-0.99, P=.046); and good knowledge about the CBHI (adjPR = 0.76, 95% CI: 0.58-0.99, P=.040). Irregular availability of healthcare workers and long waiting time affected client satisfaction.

Conclusions

Satisfaction was considerably low during the lockdown. Lockdowns due to pandemics interrupt healthcare services and subsequently affect the satisfaction of CBHI clients with scheme services. Scheme managers need to identify facilities that are closer to enrolees and invest in technologies that reduce waiting time in the healthcare facility.

Perceived barriers of access to health and nutrition services under drought and food insecurity emergency in north-east Uganda: a qualitative study

BACKGROUND

In the face of drought and food insecurity emergency, evidence on access to health and nutrition services is important. Karamoja is one of the regions that have experienced extreme drought and food insecurity emergency in Uganda. As a part of the drought and food insecurity emergency response, World Health Organization (WHO) with Ministry of Health (MoH) has designed and implemented a qualitative study in 15 districts that have experienced drought and food insecurity emergency in north-east Uganda. Thus, we aimed to explore the barriers of access to health and nutrition services in drought and food insecurity emergency affected districts in north-east Uganda.

METHODS

We employed a descriptive qualitative study design. We interviewed 30 patients and 20 Village Health Teams (VHT) from 15 districts. We employed an in-depth interview with semi-structured questions to collect data until information saturation reached. We used thematic data analysis approach by ATLAS.ti version 7.5.1.8 software.

RESULTS

Of the 30 interviewed subjects, 15 were female, and the median age of the subjects was 29 years with interquartile range (IQR) of 23 to 37 years. Majority (68.8%) of subjects reported that access to health and nutrition services was harder to them. Four themes: sociocultural and economic; environmental; health system, and individual related factors were identified as the barriers of access to health and nutrition services.

CONCLUSION

The present study identified several modifiable barriers that hinder access to health and nutrition services in drought and food insecurity affected districts. Comprehensive interventions aimed at addressing sociocultural, economic, environmental, health system and subject related challenges are required to improve access to health and nutrition services in drought and food insecurity affected setups.

Sustainability capacity and health worker normalisation of a successful non-communicable disease (NCD) health systems intervention within primary care settings in Uganda: a quantitative approach to a qualitative question

BACKGROUND

Interventions for non-communicable diseases are increasingly implemented and evaluated in sub-Saharan Africa, but little is known about their medium- to long-term sustainability beyond the end of research funding. A cluster randomised trial conducted between 2013 and 2016 in Uganda and Tanzania showed that an intervention package to improve hypertension (HT) and type-2 diabetes mellitus (DM) care was highly effective in increasing service readiness and quality of care. The present study assesses the sustainability of the intervention 4 years after the trial in Uganda.

METHODS

The study was conducted in 2020 in 22 primary care health facilities (HFs) (3 referrals and 19 lower-level units) that had received the intervention package until trial end (2016), to assess their current capacity and practice to sustain ongoing intervention activities for HT and DM care. Through a cross-sectional survey, 4 pre-defined domains (i.e., cognitive participation, coherence, collective action, and reflexive monitoring) were examined with regard to health worker (HW) normalization and 8 pre-defined domains for intervention sustainability (i.e., organisational capacity, local environment, funding stability, partnerships, communication, evaluation, adaptation, and strategic planning), using the normalisation tool and the program sustainability tool (PSAT). Summary scores were assessed by domains and facility level.

RESULTS

Overall normalization strength was adequate at 4.0 (IQR: 3.8, 4.2) of a possible 5 with no evidence of association with HF level (p = 0.40); cognitive participation (buy-in) and reflexive monitoring (appraisal) were strongest at > 4 across all HF levels. All HF levels were weak (< 4) on collective action (teamwork) and coherence (sense-making). Only collective action differed by level (p < 0.002). Overall intervention sustainability was suboptimal at 3.1 [IQR: 1.9, 4.1] of a possible 7 with weak scores on funding stability (2.0), supportive partnerships (2.2), and strategic planning (2.6). Domain differences by HF level were significant for environmental support (p = 0.02) and capacity in organisation (p = 0.01). Adequate strength at a cut-off mean of ≥5 did not differ by HF level for any domain.

CONCLUSIONS

Four years after their introduction, practice-dependent intervention elements e.g., local organisational context, HW knowledge or dedication were sustained, but external elements e.g., new funding support or attracting new partners to sustain intervention efforts were not. Whenever new interventions are introduced into an existing health service, their long-term sustainability including the required financial support should be ensured. The quality of services should be upheld by providing routine in-service training with dedicated support supervision.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had  20,000 women having

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

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Key Words

• Antenatal care
• District
• Household wealth
• Inequities
• Kenya
• Maternal education
• Model-based geostatistics
• Subnational
• Tanzania
• Travel time to healthcare
• Uganda

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MESH Headings

• Pregnancy
• Female
• Humans
• Prenatal Care
• Kenya/epidemiology
• Geography
• Maternal Death
• Uganda/epidemiology

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Grants

• EP/T003677/1 Engineering and Physical Sciences Research Council
• NIF/R1/201418 Royal Society
• Wellcome Trust
• 203077 Wellcome Trust
• 1234820N Fonds Wetenschappelijk Onderzoek

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Affiliation(s)

Peter M. Macharia Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
Noel K. Joseph Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
Gorrette Kayondo Nalwadda College of Health Sciences, Makerere University, Kampala, Uganda
Beatrice Mwilike Community Health Nursing Department, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
Aduragbemi Banke-Thomas School of Human Sciences, University of Greenwich, London, UK
Lenka Benova Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
Olatunji Johnson Department of Mathematics, The University of Manchester, Manchester, UK

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