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Wakiaga JM, Nalugala R. An examination of the structural linkages between households and community health services in realization of accelerated primary healthcare delivery in Kisumu County, Kenya: a systematic review. F1000Res 2024; 10:1082. [PMID: 39007092 PMCID: PMC11240083 DOI: 10.12688/f1000research.73303.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Background The provision of community health services (CHS) is critical in accelerating primary health care delivery to vulnerable and deprived populations. This systematic review study has been conducted to interrogate the interrelationship between households and community health services in accelerating primary healthcare delivery synthesizing the available empirical studies. The findings are to inform a primary research on structural linkages between households and CHS in Kisumu County, Kenya. Methods This study applied a descriptive approach using a systematic review technique to provide context and substance to the two main research questions: (1) how does the interaction between households and CHWs affect utilization of CHS to promote equity and right to health? (2) How do health-seeking behaviours of households influence their decision-making regarding choices of CHS? We screened the literature from Google scholar, JSTOR, SAGE and EBSCO based on our inclusion criteria, resulting in 21 studies. These studies were assessed for quality and eligibility and data extracted based on relevance to the research study. Results Households place primacy on trust and confidentiality in the interaction with CHWs and this affects uptake of CHS. The social determinants of health are also critical in influencing the health-seeking behaviour of households and individuals and their choice of CHS. The successful models of CHS share the characteristic of community ownership and participation and provides for comprehensive health care teams. Conclusion CHS are critical for the acceleration of primary health care delivery. It forms an important pathway for the achievement of universal health coverage, which is an outcome required for Sustainable Development Goal 3 on health.
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Affiliation(s)
- James M. Wakiaga
- Institute of Social Transformation, Tangaza University College, Tangaza University College, Nairobi, Kenya
| | - Reginald Nalugala
- Institute of Social Transformation, Tangaza University College, Tangaza University College, Nairobi, Kenya
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Liverani M, Phongluxa K, Phommasone K, Chew R, Chandna A, Pongvongsa T, Mayxay M, Kounnavong S, Ashley E, Lubell Y. Prospects for the development of community-based care in remote rural areas: a stakeholder analysis in Laos. BMC Health Serv Res 2024; 24:55. [PMID: 38212788 PMCID: PMC10782664 DOI: 10.1186/s12913-023-10523-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 12/23/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Community-based health programmes have been a cornerstone of primary care in Laos for decades. The study presented here aimed to document prospects for the development of current programmes, considering perceptions about health and health care priorities in the communities, implementation challenges, the policy landscape and opportunities associated with the availability of new technologies. METHODS The research design primarily involved qualitative in-depth interviews with stakeholders (n = 35) responsible for the planning, management, or implementation of community-based care in Laos at different levels of the health system. These included health managers at central departments or institutes of the Ministry of Health, provincial health departments, district health offices, heads of health centres, village health volunteers, community representatives, and international stakeholders. RESULTS There was consensus that service delivery is still a challenge in many areas, due to geographic inaccessibility of health facilities, communication barriers, health-seeking behaviour, trust, and gender discrimination, particularly among ethnic minorities. In these settings, community health workers have the potential to extend the reach of the formal health system, acting as cultural brokers across sectors of society, ethnicities, and worldviews. To maximise impact, planners need to carefully consider the implementation model, financing arrangements, health system integration, and changing health priorities in the communities. CONCLUSIONS This study examined challenges to, and opportunities for, the expansion and health system integration of community-based care in Laos. Further development and horizontal integration of community-based care remains a complex financing and governance challenge, although the renewed emphasis on primary care and the ongoing process of decentralisation provide a favourable policy environment in the country to sustain and potentially expand existing programmes.
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Affiliation(s)
- Marco Liverani
- London School of Hygiene and Tropical Medicine, London, UK.
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
- Faculty of Public Health, Mahidol University, Bangkok, Thailand.
| | - Khampheng Phongluxa
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Koukeo Phommasone
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Vientiane, Lao People's Democratic Republic
| | - Rusheng Chew
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Arjun Chandna
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | | | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Institute of Research and Education Development, University of Health Sciences, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Elizabeth Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Grant M, Bhana A, Kathree T, Khuzwayo N, van Rensburg AJ, Mthethwa L, Gigaba S, Ntswe E, Luvuno Z, Petersen I. The feasibility of a Community Mental Health Education and Detection (CMED) tool in South Africa. SSM - MENTAL HEALTH 2023; 3:100188. [PMID: 38903557 PMCID: PMC11189615 DOI: 10.1016/j.ssmmh.2023.100188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Poor mental health literacy, misinformation about treatment and stigma result in low demand for mental health services in low-and middle-income countries. Community-based interventions that raise mental health awareness and facilitate detection of mental health conditions, are instrumental in increasing demand through strengthened mental health literacy, as well as supply of available mental health services through strengthened detection and linkage to care. Objective To assess the feasibility of a Community Mental Health Education and Detection Tool (CMED) for use with household members by community health teams in South Africa. Methods The feasibility of using the CMED in households was assessed using Bowen et al.'s framework which informed the study design, interview tools and analysis. The feasibility study involved four phases: (1) observations of the CMED consultation to evaluate the administration of the tool; (2) semi-structured interviews with household member/s after the CMED was administered to explore experiences of the visit; (3) follow-up interviews of household members referred using the CMED tool to assess uptake of referrals; (4) and weekly focus group discussions with the community health team to explore experiences of using the tool. Framework analysis was used to inform a priori themes and allow inductive themes to emerge from the data. Results The CMED was found to be acceptable by both community health teams and household members, demand for the tool was evident, implementation, practicality and integration within the existing health system were also indicated. Conclusion The CMED is perceived as feasible by household members and community health teams, suggesting a 'goodness of fit" within the existing health system.
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Affiliation(s)
- Merridy Grant
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- SA Medical Research Council Health Systems Research Unit, Durban, South Africa
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Nonkululeko Khuzwayo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - André J van Rensburg
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Londiwe Mthethwa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Sithabisile Gigaba
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ellen Ntswe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Zamasomi Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Topp SM, Tully J, Cummins R, Graham V, Yashadhana A, Elliott L, Taylor S. Rhetoric, Reality and Racism: The Governance of Aboriginal and Torres Strait Islander Health Workers in a State Government Health Service in Australia. Int J Health Policy Manag 2022; 11:2951-2963. [PMID: 35569001 PMCID: PMC10105169 DOI: 10.34172/ijhpm.2022.6750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 04/22/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In northern Australia, Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are unique members of nominally integrated teams of primary care professionals. Spurred by research documenting ongoing structural violence experienced by Indigenous health providers and more recent challenges to recruitment and retention of A&TSIHWs, this study aimed to explore whether the governance of the A&TSIHW role supports full and meaningful participation. METHODS The qualitative study was co-designed by a team of Aboriginal, Torres Strait Islander and non-Indigenous collaborators. Data collection comprised document review and interviews with A&TSIHWs (n=51), clinicians (n=19) community members (n=8) and administrators (n=5) in a north Queensland health district. We analysed governance at multiple levels (regulatory, organisational, and socio-cultural) and used critical race theory to deepen exploration of the role of race and racism in shaping it. RESULTS Governance of the A&TSIHW role occurs within a health system where racism is built into, and amplified by, formal and informal rules at all levels. Racially discriminatory structures such as the previous but long-standing relegation of A&TSIHW into the same career stream as cleaners were mirrored in discriminatory rules and managerial practices such as an absence of career-specific corporate support and limited opportunities to participate in, or represent to, key leadership groups. These interacted with and helped perpetuate workplace norms permissive of disrespect and abuse by non-Indigenous professionals. Ongoing resistance to the structural violence required of, and demonstrated by A&TSIHWs speaks to the gap between rhetoric and reality of governance for A&TSIHWs. CONCLUSION Strengthening governance to support A&TSIHWs requires critical attention be given to the role of race and racism in regulatory structures, organisational practice, and inter-professional relationships. Addressing all domains will be essential to achieve systemic change that recognises, supports and embeds the unique knowledge, skills and functions of the A&TSIHW role.
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Affiliation(s)
- Stephanie M. Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Josslyn Tully
- Torres and Cape Hospital and Health Services (TCHSS), Cairns, QLD, Australia
| | - Rachel Cummins
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Veronica Graham
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Aryati Yashadhana
- Centre for Primary Health Care & Equity, University of New South Wales, Sydney, NSW, Australia
- School of Population Health, UNSW, Sydney, NSW, Australia
- School of Social Sciences, UNSW, Sydney, NSW, Australia
| | - Lana Elliott
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
- School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Sean Taylor
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
- NT Health, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
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Garg S, Dewangan M, Nanda P, C K, Sahu A, Xalxo L. Assessing the time use and payments of multipurpose community health workers for the various roles they play-a quantitative study of the Mitanin programme in India. BMC Health Serv Res 2022; 22:1018. [PMID: 35948908 PMCID: PMC9364297 DOI: 10.1186/s12913-022-08424-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
Background Community health workers (CHWs) are crucial human resources for health. While specialist CHWs focus on a single disease vertically, the generalist or multipurpose CHWs perform wider functions. The current study was aimed at examining the time multipurpose CHWs spend on performing their different roles. This can help in understanding the importance they attach to each role. Since CHWs in many developing countries are classified as part-time volunteers, this study also aimed to assess the adequacy of CHW payments in relation to their time use. Methods The study covered a well-established CHW programme in India's Chhattisgarh state. It had 71,000 multipurpose part-time CHWs known as Mitanins. Data collection involved interviews with a representative sample of 660 rural and 406 urban Mitanins. A semi-structured tool was designed and field tested. It included 26 pre-coded activities of CHWs placed under their six purposes or roles. Prompting and triangulation were used during interviews to mitigate the possibility of over-reporting of work by CHWs. The recall period was of one week. Descriptive analysis included comparison of key indicators for rural and urban Mitanins. A multi-variate linear model was used to find the determinants of CHW time-use. Results The rural and urban Mitanins respectively spent 25.3 and 34.8 h per week on their CHW work. Apart from location (urban), the total time spent was associated with size of population covered. The time-use was well balanced between roles of service-linkage, providing health education and curative care directly, COVID-19 related work and action on social determinants of health. More than half of their time-use was for unpaid tasks. Most of the cash-incentives were concentrated on service linkage role. The average payment earned by Mitanins was less than 60% of legal minimum wage. Conclusion The time-use pattern of Mitanins was not dictated by cash-incentives and their solidarity with community seemed be a key motivator. To allow wide ranging CHW action like Mitanins, the population per CHW should be decided appropriately. The considerable time multipurpose CHWs spend on their work necessitates that developing countries develop policies to comply with World Health Organisation's recommendation to pay them fairly. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08424-1.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Chhattisgarh, Raipur, India.
| | | | - Prabodh Nanda
- State Health Resource Centre, Chhattisgarh, Raipur, India
| | - Krishnendhu C
- State Health Resource Centre, Chhattisgarh, Raipur, India
| | - Ashu Sahu
- State Health Resource Centre, Chhattisgarh, Raipur, India
| | - Lalita Xalxo
- State Health Resource Centre, Chhattisgarh, Raipur, India
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Conceptualising the Factors Influencing Community Health Workers’ Preparedness for ICT Implementation: A Systematised Scoping Review. SUSTAINABILITY 2022. [DOI: 10.3390/su14148930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Background: Globally, community health workers (CHW) are increasingly viewed as an integral part of the health system as opposed to simply being an extension of it. Given this view, most low- or middle-income countries (LMICs) have refocused their efforts on reorganising CHW initiatives to maximise their impact. The ongoing endeavours to augment the practice of community health workers using technological solutions are characterised by as many challenges as opportunities. In low- and middle-income countries, including South Africa, information and communication technology (ICT) has become a promising development in the enhancement of the equitable coverage of health services by community health workers. However, there has not been a wide-scale implementation and adoption of ICT; most technology initiatives fail to scale up during the implementation stage, which is attributable to human and context-related factors. Although there has been an effort to develop solutions to address ICT infrastructure and technical barriers, conceptualising an evidence-based understanding of the contextual and user-related factors that influence the efficacy of technology adoption by CHWs within their multidimensional system remains critical. Objective: The purpose of the study is to conceptualise the social factors to consider when implementing a bespoke ICT solution suited to the specific demands of CHWs in primary healthcare in developing contexts, with a particular focus on the South African context. Methodology: The methodology involves synthesizing, extracting, and consolidating the findings of a systematised scoping review into concepts and factors. The review adapts Arksey and O’Malley’s scoping review approach to the study and incorporates 59 relevant articles. Results: Although the knowledge base on CHWs is extensive, there is a considerable gap in addressing structural challenges within the community system, which contributes significantly to the overall performance of CHW programs. Factors promoting policy adaptations, common practice within the health system, CHW competencies, a community’s development in terms of knowledge and economic advancement, safety and security, the environment, and the socio-cultural context all play a significant role in facilitating or impeding the success of health interventions from the individual to the national level. Conclusions: Within several practical limitations, the study shows that despite the efforts of various developing countries to promote technology adoption, the barriers to ICT adoption outweigh the benefits gained in developing countries. The paper argues that addressing these challenges before and during implementation is critical. The authors conclude with some essential concerns about assisting CHWs towards realising the desired health outcomes through ICT.
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Karim A, de Savigny D, Awor P, Cobos Muñoz D, Mäusezahl D, Kitoto Tshefu A, Ngaima JS, Enebeli U, Isiguzo C, Nsona H, Ogbonnaya I, Ngoy P, Alegbeleye A. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health 2022; 7:bmjgh-2022-008493. [PMID: 35772810 PMCID: PMC9247653 DOI: 10.1136/bmjgh-2022-008493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/30/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. Methods We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. Results The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. Conclusion The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.
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Affiliation(s)
- Aliya Karim
- University of Basel, Basel, Switzerland .,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Don de Savigny
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Cobos Muñoz
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Daniel Mäusezahl
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Jean Serge Ngaima
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ugo Enebeli
- Department of Community Medicine, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Chinwoke Isiguzo
- School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Society for Family Health Nigeria, Abuja, Nigeria
| | - Humphreys Nsona
- IMCI, Malawi Ministry of Health, Lilongwe, Central Region, Malawi
| | - Ikechi Ogbonnaya
- Department of Health, Planning, Research & Statistics, Federal Ministry of Health, Abuja, Federal Capital Territory, Nigeria
| | - Pascal Ngoy
- PROSANI, USAID, Washington, District of Columbia, USA
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Pinto RM, Rahman R, Zanchetta MS, Galhego-Garcia W. Brazil's Community Health Workers Practicing Narrative Medicine: Patients' Perspectives. J Gen Intern Med 2021; 36:3743-3751. [PMID: 33826059 PMCID: PMC8642505 DOI: 10.1007/s11606-021-06730-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/16/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Narrative medicine (NM) encourages health care providers to draw on their personal experiences to establish therapeutic alliances with patients of prevention and care services. NM medicine practiced by nurses and physicians has been well documented, yet there is little understanding of how community health workers (CHWs) apply NM concepts in their day-to-day practices from patient perspectives. OBJECTIVE To document how CHWs apply specific NM concepts in Brazil's Family Health Strategy (FHS), the key component of Brazil's Unified Health System. DESIGN We used a semi-structured interview, grounded in Charon's (2001) framework, including four types of NM relationships: provider-patient, provider-colleague, provider-society, and provider-self. A hybrid approach of thematic analysis was used to analyze data from 27 patients. KEY RESULTS Sample: 18 females; 13 White, 12 "Pardo" (mixed races), 12 Black. We found: (1) provider-patient relationship-CHWs offered health education through compassion, empathy, trustworthiness, patience, attentiveness, jargon-free communication, and altruism; (2) provider-colleague relationship-CHWs lacked credibility as perceived by physicians, impacting their effectiveness negatively; (3) provider-society relationship-CHWs mobilized patients civically and politically to advocate for and address emerging health care and prevention needs; (4) provider-self relationship-patients identified possible low self-esteem among CHWs and a need to engage in self-care practices to abate exhaustion from intense labor and lack of resources. CONCLUSION This study adds to patient perspectives on how CHWs apply NM concepts to build and sustain four types of relationships. Findings suggest the need to improve provider-colleague relationships by ongoing training to foster cooperation among FHS team members. More generous organizational supports (wellness initiatives and supervision) may facilitate the provider-self relationship. Public education on CHWs' roles is needed to enhance the professional and societal credibility of their roles and responsibilities. Future research should investigate how CHWs' personality traits may influence their ability to apply NM.
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Affiliation(s)
| | - Rahbel Rahman
- Graduate School of Social Service, Fordham University, New York, NY, USA
| | | | - W Galhego-Garcia
- Department of Basic Sciences, Faculty of Dentistry of Araçatuba, Estadual Paulista University, São Paulo, Brazil
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Lewin S, Lehmann U, Perry HB. Community health workers at the dawn of a new era: 3. Programme governance. Health Res Policy Syst 2021; 19:129. [PMID: 34641914 PMCID: PMC8506073 DOI: 10.1186/s12961-021-00749-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on "Community Health Workers at the Dawn of a New Era", aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved. METHODS We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes. RESULTS Governing comprises the processes and structures through which individuals, groups, programmes, and organizations exercise rights, resolve differences, and express interests. Because CHW programmes are located between the formal health system and communities, and because they involve a wide range of stakeholders, their governance is complex. In addition, these programmes frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programmes more challenging. We discuss the following important questions that decision-makers need to consider in relation to governing CHW programmes: (1) How and where within political structures are policies made for CHW programmes? (2) Who implements decisions regarding CHW programmes and at what levels of government? (3) What laws and regulations are needed to support the programme? (4) How should the programme be adapted across different settings or groups within the country or region? CONCLUSION The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to local needs and systems.
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Affiliation(s)
- Simon Lewin
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Kane S, Radkar A, Gadgil M, McPake B. Community Health Workers as Influential Health System Actors and not "Just Another Pair Of Hands". Int J Health Policy Manag 2021; 10:465-474. [PMID: 32610755 PMCID: PMC9056200 DOI: 10.34172/ijhpm.2020.58] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 04/13/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Over the last 20 years, community health workers (CHWs) have become a mainstay of human resources for health in many low- and middle-income countries (LMICs). A large body of research chronicles CHWs' experience of their work. In this study we focus on 2 narratives that stand out in the literature. The first is the idea that social, economic and health system contexts intersect to undermine CHWs' experience of their work, and that a key factor underpinning this experience is that LMIC health systems tend to view CHWs as just an 'extra pair of hands' to be called upon to provide 'technical fixes.' In this study we show the dynamic and evolving nature of CHW programmes and CHW identities and the need, therefore, for new understandings. METHODS A qualitative case study was carried out of the Indian CHW program (CHWs are called accredited social health activists: ASHAs). It aimed to answer the research question: How do ASHAs experience being CHWs, and what shapes their experience and performance? In depth interviews were conducted with 32 purposively selected ASHAs and key informants. Analysis was focused on interpreting and on developing analytical accounts of ASHAs' experiences of being CHWs; it was iterative and occurred throughout the research. Interviews were transcribed verbatim and transcripts were analysed using a framework approach (with Nvivo 11). RESULTS CHWs resent being treated as just another pair of hands at the beck and call of formal health workers. The experience of being a CHW is evolving, and many are accumulating substantial social capital over time - emerging as influential social actors in the communities they serve. CHWs are covertly and overtly acting to subvert the structural forces that undermine their performance and work experience. CONCLUSION CHWs have the potential to be influential actors in the communities they serve and in frontline health services. Health systems and health researchers need to be cognizant of and consciously engage with this emerging global social dynamic around CHWs. Such an approach can help guide the development of optimal strategies to support CHWs to fulfil their role in achieving health and social development goals.
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Affiliation(s)
- Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
- Gokhale Institute of Politics and Economics, Pune, Maharashtra, India
| | - Anjali Radkar
- Gokhale Institute of Politics and Economics, Pune, Maharashtra, India
| | - Mukta Gadgil
- State Health Systems Resource Centre, Pune, Maharashtra, India
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
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11
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Yasobant S, Bruchhausen W, Saxena D, Memon FZ, Falkenberg T. Health System Contact and Awareness of Zoonotic Diseases: Can it Serve as One Health Entry Point in the Urban Community of Ahmedabad, India? THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:259-269. [PMID: 34211346 PMCID: PMC8223553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
One Health (OH) is emphasized globally to tackle the (re)emerging issues at the human-animal-ecosystem interface. However, the low awareness about zoonoses remain a challenge in global south, thus this study documented the health system contact and its effect on the awareness level of zoonoses in the urban community of Ahmedabad, India. A community-based household survey was conducted between October 2018 and July 2019. A total of 460 households (HHs) were surveyed from two zones and 23 wards of the city through cluster sampling. A structured, pilot-tested, and researcher-administered questionnaire in the vernacular language was used to collect the information on demographic details, socio-economic details, health-seeking behavior for both the humans and their animals, human and animal health system contact details and the participants' awareness on selected zoonotic diseases based on the prioritization (rabies, brucellosis, swine flu, and bird flu). Out of 460 surveyed households, 69% of HHs and 59% of HHs had a health system contact to the human and animal health system respectively at the community level. There are multiple health workers active on the community level that could potentially serve as One Health liaisons. The investigation of the knowledge and awareness level of selected zoonotic diseases revealed that 58.5%, 47.6%, and 4.6% know about rabies, swine and/or bird flu, and brucellosis, respectively. The mixed-effect linear regression model indicates that there is no significant effect on the zoonotic disease awareness score with the human health system contact; however, a minimal positive effect with the animal health system contact was evident.
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Affiliation(s)
- Sandul Yasobant
- Center for Development Research (ZEF), University of
Bonn, Bonn, Germany,Global Health, Institute for Hygiene and Public Health
(IHPH), University Hospital Bonn, Bonn, Germany,To whom all correspondence should be addressed:
Sandul Yasobant, MPH, PhD, Center for Development Research (ZEF), Genscherallee
3, 53113 Bonn, Germany; Tel: +91-98761357331,
; ORCID iD: https://orcid.org/0000-0003-1770-8745
| | - Walter Bruchhausen
- Center for Development Research (ZEF), University of
Bonn, Bonn, Germany,Global Health, Institute for Hygiene and Public Health
(IHPH), University Hospital Bonn, Bonn, Germany
| | - Deepak Saxena
- Indian Institute of Public Health Gandhinagar (IIPHG),
Gandhinagar, India,Jawaharlal Nehru Medical College, Datta Meghe Institute
of Medical Sciences, Wardha, India
| | | | - Timo Falkenberg
- Center for Development Research (ZEF), University of
Bonn, Bonn, Germany,GeoHealth Centre, Institute for Hygiene and Public
Health (IHPH), University Hospital Bonn, Bonn, Germany
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12
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Schaaf M, Warthin C, Freedman L, Topp SM. The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability. BMJ Glob Health 2021; 5:bmjgh-2020-002296. [PMID: 32546585 PMCID: PMC7299037 DOI: 10.1136/bmjgh-2020-002296] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022] Open
Abstract
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.
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Affiliation(s)
| | - Caitlin Warthin
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lynn Freedman
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
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13
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Allen KC, Whitfield K, Rabinovich R, Sadruddin S. The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses. BMJ Glob Health 2021; 6:bmjgh-2020-003257. [PMID: 33789866 PMCID: PMC8016094 DOI: 10.1136/bmjgh-2020-003257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 02/26/2021] [Accepted: 03/04/2021] [Indexed: 01/16/2023] Open
Abstract
Improving health outcomes in countries with the greatest burden of under-5 child mortality requires implementing innovative approaches like integrated community case management (iCCM) to improve coverage and access for hard-to-reach populations. ICCM improves access for hard-to-reach populations by deploying community health workers to manage malaria, diarrhoea and pneumonia. Despite documented impact, challenges remain in programme implementation and sustainability. An analytical review was conducted using evidence from published and grey literature from 2010 to 2019. The goal was to understand the link between governance, policy development and programme sustainability for iCCM. A Governance Analytical Framework revealed thematic challenges and successes for iCCM adaptation to national health systems. Governance in iCCM included the collective problems, actors in coordination and policy-setting, contextual norms and programmatic interactions. Key challenges were country leadership, contextual evidence and information-sharing, dependence on external funding, and disease-specific stovepipes that impede funding and coordination. Countries that tailor and adapt programmes to suit their governance processes and meet their specific needs and capacities are better able to achieve sustainability and impact in iCCM.
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Affiliation(s)
- Koya C Allen
- Malaria Eradication Scientific Alliance (MESA), Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Kate Whitfield
- Malaria Eradication Scientific Alliance (MESA), Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Regina Rabinovich
- Malaria Elimination Initiative, Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain.,ExxonMobil Malaria Scholar in Residence, Department of Immunology and Infectious Diseases, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Salim Sadruddin
- Child Health, MOMENTUM Country and Global Leadership, Washington, DC, USA
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14
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Dodd W, Kipp A, Nicholson B, Lau LL, Little M, Walley J, Wei X. Governance of community health worker programs in a decentralized health system: a qualitative study in the Philippines. BMC Health Serv Res 2021; 21:451. [PMID: 33980209 PMCID: PMC8114679 DOI: 10.1186/s12913-021-06452-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/26/2021] [Indexed: 12/22/2022] Open
Abstract
Background Community health worker (CHW) programs are an important resource in the implementation of universal health coverage (UHC) in many low- and middle-income countries (LMICs). However, in countries with decentralized health systems like the Philippines, the quality and effectiveness of CHW programs may differ across settings due to variations in resource allocation and local politics. In the context of health system decentralization and the push toward UHC in the Philippines, the objective of this study was to explore how the experiences of CHWs across different settings were shaped by the governance and administration of CHW programs. Methods We conducted 85 semi-structured interviews with CHWs (n = 74) and CHW administrators (n = 11) in six cities across two provinces (Negros Occidental and Negros Oriental) in the Philippines. Thematic analysis was used to analyze the qualitative data with specific attention to how the experiences of participants differed within and across geographic settings. Results Health system decentralization contributed to a number of variations across settings including differences in the quality of human resources and the amount of financial resources allocated to CHW programs. In addition, the quality and provider of CHW training differed across settings, with implications for the capacity of CHWs to address specific health needs in their community. Local politics influenced the governance of CHW programs, with CHWs often feeling pressure to align themselves politically with local leaders in order to maintain their employment. Conclusions The functioning of CHW programs can be challenged by health system decentralization through the uneven operationalization of national health priorities at the local level. Building capacity within local governments to adequately resource CHWs and CHW programs will enhance the potential of these programs to act as a bridge between the local health needs of communities and the public health system. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06452-x.
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Affiliation(s)
- Warren Dodd
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, N2L 3G1, Canada.
| | - Amy Kipp
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, N2L 3G1, Canada
| | - Bethany Nicholson
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, N2L 3G1, Canada
| | | | - Matthew Little
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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15
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Kamau J, Ashby E, Shields L, Yu J, Murray S, Vodzak M, Kwallah AO, Ambala P, Zimmerman D. The intersection of land use and human behavior as risk factors for zoonotic pathogen exposure in Laikipia County, Kenya. PLoS Negl Trop Dis 2021; 15:e0009143. [PMID: 33606671 PMCID: PMC7894889 DOI: 10.1371/journal.pntd.0009143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 01/13/2021] [Indexed: 12/23/2022] Open
Abstract
A majority of emerging infectious diseases (EIDs) are zoonotic, mainly caused through spillover events linked to human-animal interactions. We conducted a survey-based human behavioral study in Laikipia County, Kenya, which is characterized by a dynamic human-wildlife-livestock interface. Questionnaires that assessed human-animal interactions, sanitation, and illnesses experienced within the past year were distributed to 327 participants among five communities in Laikipia. This study aimed to 1) describe variation in reported high-risk behaviors by community type and 2) assess the relationship between specific behaviors and self-reported illnesses. Behavioral trends were assessed in R via Fisher’s exact tests. A generalized linear mixed model with Lasso penalization (GLMMLasso) was used to assess correlations between behaviors and participants’ self-reported illness within the past year, with reported behaviors as independent variables and reported priority symptoms as the outcome. Reported behaviors varied significantly among the study communities. Participants from one community (Pastoralist-1) were significantly more likely to report eating a sick animal in the past year (p< 0.001), collecting an animal found dead to sell in the past year (p<0.0001), and not having a designated location for human waste (p<0.0001) when compared to participants from other communities. The GLMMLasso revealed that reports of an ill person in the household in the past year was significantly associated with self-reported illness. Sixty-eight percent of participants reported that bushmeat is available within the communities. Our study demonstrates community-level variation in behaviors that may influence zoonotic pathogen exposure. We further recommend development of targeted studies that explore behavioral variations among land use systems in animal production contexts. Many infectious diseases, such as H1N1, Ebola, and COVID-19, can be spread to humas from animals. In order to reduce the risk of disease “spillover” (disease transmission from an animal to a person), it is important to understand how interactions between humans and animals can influence spread. Certain behaviors, such as eating raw meat, hunting, or sharing drinking water with animals can put people at greater risk of contacting bacteria and viruses that can cause these diseases. Globally, communities that depend on animal production are at heightened risk due to increased contact with animals. In this study, the authors conducted human behavioral surveys among different communities in Kenya that raise livestock. Results show that reported behaviors varied greatly by community. One of the communities reported a significantly higher proportion of behaviors, such as eating raw meat or eating animals found dead. Communities that show high prevalence of these behaviors may be at greater risk for contracting diseases from animals. Understanding this variation is important for developing plans for community outreach and addressing behaviors that can influence risk of disease spread.
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Affiliation(s)
| | - Elizabeth Ashby
- Department of Environmental Science and Policy, George Mason University, Fairfax, Virginia, United States of America
- * E-mail:
| | | | - Jennifer Yu
- Global Health Program, Smithsonian Conservation Biology Institute, Smithsonian Institution, Washington, DC, United States of America
| | - Suzan Murray
- Global Health Program, Smithsonian Conservation Biology Institute, Smithsonian Institution, Washington, DC, United States of America
| | - Megan Vodzak
- Global Health Program, Smithsonian Conservation Biology Institute, Smithsonian Institution, Washington, DC, United States of America
| | | | - Peris Ambala
- Institute of Primate Research, Nairobi, Kenya
- Department of Biochemistry, Kenyatta University, Nairobi, Kenya
| | - Dawn Zimmerman
- Global Health Program, Smithsonian Conservation Biology Institute, Smithsonian Institution, Washington, DC, United States of America
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16
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Kumar MB, Taegtmeyer M, Madan J, Ndima S, Chikaphupha K, Kea A, Barasa E. How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries. Health Policy Plan 2020; 35:799-809. [PMID: 32516361 PMCID: PMC7487332 DOI: 10.1093/heapol/czaa027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2020] [Indexed: 11/29/2022] Open
Abstract
Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems-i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.
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Affiliation(s)
- Meghan Bruce Kumar
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Miriam Taegtmeyer
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Jason Madan
- Centre for Health Economics at Warwick, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sozinho Ndima
- Community Health Department, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Aschenaki Kea
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
- Center for International Health, University of Bergen, Bergen, Norway
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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17
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Griffiths F, Babalola O, Brown C, de Kadt J, Malatji H, Thorogood M, Tseng YH, Goudge J. Development of a tool for assessing quality of comprehensive care provided by community health workers in a community-based care programme in South Africa. BMJ Open 2019; 9:e030677. [PMID: 31492789 PMCID: PMC6731907 DOI: 10.1136/bmjopen-2019-030677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/19/2019] [Accepted: 07/29/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To develop a tool for use by non-clinical fieldworkers for assessing the quality of care delivered by community health workers providing comprehensive care in households in low- and middle-income countries. DESIGN We determined the content of the tool using multiple sources of information, including interactions with district managers, national training manuals and an exploratory study that included observations of 70 community health workers undertaking 518 household visits collected as part of a wider study. We also reviewed relevant literature, selecting relevant domains and quality markers. To refine the tool and manual we worked with the fieldworkers who had undertaken the observations. We constructed two scores summarising key aspects of care: (1) delivering messages and actions during household visit, and (2) communicating with the household; we also collected contextual data. The fieldworkers used the tool with community health workers in a different area to test feasibility. SETTING South Africa, where community health workers have been brought into the public health system to address the shortage of healthcare workers and limited access to healthcare. It was embedded in an intervention study to improve quality of community health worker supervision. PRIMARY AND SECONDARY OUTCOMES Our primary outcome was the completion of a tool and user manual. RESULTS The tool consists of four sections, completed at different stages during community health worker household visits: before setting out, at entry to a household, during the household visit and after leaving the household. Following tool refinement, we found no problems on field-testing the tool. CONCLUSIONS We have developed a tool for assessing quality of care delivered by community health workers at home visits, often an unobserved part of their role. The tool was developed for evaluating an intervention but could also be used to support training and management of community health workers.
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Affiliation(s)
- Frances Griffiths
- University of Warwick Warwick Medical School, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Olukemi Babalola
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Celia Brown
- University of Warwick Warwick Medical School, Coventry, UK
| | - Julia de Kadt
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Hlologelo Malatji
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Margaret Thorogood
- University of Warwick Warwick Medical School, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Yu-Hwei Tseng
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Jane Goudge
- Centre for Health Policy, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
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18
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Assegaai T, Schneider H. National guidance and district-level practices in the supervision of community health workers in South Africa: a qualitative study. HUMAN RESOURCES FOR HEALTH 2019; 17:25. [PMID: 30943986 PMCID: PMC6446406 DOI: 10.1186/s12960-019-0360-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/11/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Supportive supervision is considered critical to community health worker programme performance, but there is relatively little understanding of how it can be sustainably done at scale. Supportive supervision is a holistic concept that encompasses three key functions: management (ensuring performance), education (promoting development) and support (responding to needs and problems). Drawing on the experiences of the ward-based outreach team (WBOT) strategy, South Africa's national community health worker (CHW) programme, this paper explores and describes approaches to supportive supervision in policy and programme guidelines and how these are implemented in supervision practices in the North West Province, an early adopter of the WBOT strategy. Outreach teams typically consist of six CHWs plus a nurse outreach team leader (OTL). METHODS A qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province was conducted. An overall WBOT policy statement and four guidelines on aspects of the strategy, spanning the period 2011-2017, were reviewed for statements on the three core facets of supervision outlined above. Eight focus group discussions, involving facility managers, team leaders and community health workers (total 40 respondents), purposively selected from four sub-districts in two districts, assessed local-level supervision practices. Alignment across policy and guidance documents and between policy/guidance and practice was examined. FINDINGS While all the official policy documents and guidelines reviewed acknowledged the need for supervision and support, these elements were inadequately developed and poorly aligned, both in terms of scope and in providing firm guidance on the supervision of WBOTs. The practices of supervision entailed a variety of reporting lines, while development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams amongst CHWs and between CHWs and OTLs. However, primary health care clinic managers, who were supposed to supervise the WBOTs, struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained. CONCLUSION This study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit, coherent and holistic guidance in policy and the failure to address constraints to supervision at local level undermine the performance and sustainability of the WBOT strategy in South Africa.
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Affiliation(s)
- Tumelo Assegaai
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Helen Schneider
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- University of the Western Cape/South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa
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