Examining the evidence for best practice guidelines in supportive supervision of lay health care providers in humanitarian emergencies: A systematic scoping review

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health system strengthening in fragile and conflict-affected states: A review of systematic reviews

BACKGROUND

Globally, there is growing attention towards health system strengthening, and the importance of quality in health systems. However, fragile and conflict-affected states present particular challenges. The aim of this study was to explore health system strengthening in fragile and conflict-affected states by synthesising the evidence from published literature.

METHODS

We conducted a review of systematic reviews (Prospero Registration Number: CRD42022371955) by searching Ovid (Medline, Embase, and Global Health), Scopus, Web of Science, and the Cochrane Library databases. Only English-language publications were considered. The Joanna Briggs Institute (JBI) Critical Appraisal Tool was employed to assess methodological quality of the included studies. The findings were narratively synthesised and presented in line with the Lancet's 'high-quality health system framework'.

RESULTS

Twenty-seven systematic reviews, out of 2,704 identified records, considered key dimensions of health systems in fragile and conflict-affected states, with the 'foundations' domain having most evidence. Significant challenges to health system strengthening, including the flight of human capital due to safety concerns and difficult working conditions, as well as limited training capacities and resources, were identified. Facilitators included community involvement, support systems and innovative financing mechanisms. The importance of coordinated and integrated responses tailored to the context and stage of the crisis situation was emphasised in order to strengthen fragile health systems. Overall, health system strengthening initiatives included policies encouraging the return and integration of displaced healthcare workers, building local healthcare workers capacity, strengthening education and training, integrating healthcare services, trust-building, supportive supervision, and e-Health utilisation.

CONCLUSION

The emerging body of evidence on health system strengthening in fragile and conflict-affected states highlights its complexity. The findings underscore the significance of adopting a comprehensive approach and engaging various stakeholders in a coordinated manner considering the stage and context of the situation.

Five recommendations to advance implementation science for humanitarian settings: the next frontier of humanitarian research

Challenges in delivering evidence-based programming in humanitarian crises require new strategies to enhance implementation science for better decision-making. A recent scoping review highlights the scarcity of peer-reviewed studies on implementation in conflict zones. In this commentary, we build on this scoping review and make five recommendations for advancing implementation science for humanitarian settings. These include (1) expanding existing frameworks and tailoring them to humanitarian dynamics, (2) utilizing hybrid study designs for effectiveness-implementation studies, (3) testing implementation strategies, (4) leveraging recent methodological advancements in social and data science, and (5) enhancing training and community engagement. These approaches aim to address gaps in understanding intervention effectiveness, scale, sustainability, and equity in humanitarian settings. Integrating implementation science into humanitarian research is essential for informed decision-making and improving outcomes for affected populations.

A new scale to assess health-facility level management: the development and validation of the facility management scale in Ghana, Uganda, and Malawi

BACKGROUND

The increased recognition of governance, leadership, and management as determinants of health system performance has prompted calls for research focusing on the nature, quality, and measurement of this key health system building block. In low- or middle-income contexts (LMIC), where facility-level management and performance remain a challenge, valid tools to measure management have the potential to boost performance and accelerate improvements. We, therefore, sought to develop a Facility-level Management Scale (FMS) and test its reliability in the psychometric properties in three African contexts.

METHODS

The FMS was administered to 881 health workers in; Ghana (n = 287; 32.6%), Malawi (n = 66; 7.5%) and Uganda (n = 528; 59.9%). Half of the sample data was randomly subjected to exploratory factor analysis (EFA) and Monte Carlo Parallel Component Analysis to explore the FMS' latent structure. The construct validity of this structure was then tested on the remaining half of the sample using confirmatory factor analysis (CFA). The FMS' convergent and divergent validity, as well as internal consistency, were also tested.

RESULTS

Findings from the EFA and Monte Carlo PCA suggested the retention of three factors (labelled 'Supportive Management', 'Resource Management' and 'Time management'). The 3-factor solution explained 51% of the variance in perceived facility management. These results were supported by the results of the CFA (N = 381; χ2 = 256.8, df = 61, p < 0.001; CFI = 0.94; TLI = 0.92; RMSEA [95% CI] = 0.065 [0.057-0.074]; SRMR = 0.047).

CONCLUSION

The FMS is an open-access, short, easy-to-administer scale that can be used to assess how health workers perceive facility-level management in LMICs. When used as a regular monitoring tool, the FMS can identify key strengths or challenges pertaining to time, resources, and supportive management functions at the health facility level.

Barriers and Facilitators to Implementing a Community-Based Psychosocial Support Intervention Conducted In-Person and Remotely: A Qualitative Study in Quibdó, Colombia

Community-based psychosocial support group (CB-PSS) interventions using task-shifting approaches are well suited to provide culturally appropriate services in low- and middle-income countries. However, contextual barriers and facilitators must be considered to tailor interventions effectively, particularly considering the challenges introduced by the COVID-19 pandemic. We explore the barriers, facilitators, and psychosocial changes associated with implementing a CB-PSS group intervention delivered by local lay providers to conflict-affected adults in Quibdó, Colombia, using both in-person and remote modalities. Data were analyzed from 25 individual interviews with participants and a focus group discussion involving staff members, including 7 community psychosocial agent facilitators and 2 mental health professional supervisors. The analysis used a thematic approach grounded in a descriptive phenomenology to explore the lived experiences of participants and staff members during implementation. Participant attendance in the in-person modality was compromised by factors such as competing work and family responsibilities and disruption caused by the COVID-19 pandemic. Participants in the remote modality faced challenges concerning unstable Internet connectivity, recurrent power outages caused by heavy rain, distractions, interruptions, and threats to confidentiality by family and coworkers. Despite these challenges, data revealed key contextual facilitators, including the community-based knowledge of facilitators and integration of traditional practices, such as the comadreo (informal talks and gatherings). Respondents shared that the CB-PSS groups promoted stronger community relationships and created opportunities for participants to exchange peer support, practice leadership skills, develop problem-solving skills based on peers' experiences, and enhance emotional regulation skills. Differences and similarities across in-person and remote modalities are discussed, as are key considerations for practitioners and policymakers.

Testing the effectiveness and acceptability of online supportive supervision for mental health practitioners in humanitarian settings: a study protocol for the caring for carers project

BACKGROUND

Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project.

METHOD

A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress (Professional Quality of Life Scale), perceived injustice, clinical self-efficacy (Counseling Activity Self-Efficacy Scale), service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention.

DISCUSSION

There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.

Feasibility and acceptability of a peer provider delivered substance use screening and brief intervention program for youth in Kenya

BACKGROUND

Youth in sub-Saharan Africa are at high risk of substance use yet lack access to substance use interventions. The goal of this project was to evaluate the feasibility and acceptability of a peer-delivered, single-session substance use screening and brief intervention program for youth in Kenya.

METHODS

This was a convergent parallel mixed methods study utilizing both quantitative and qualitative approaches. Two trained peer providers administered the screening and brief intervention program to 100 youth aged 15-24 years. To evaluate the implementation of the intervention, we collected quantitative and qualitative data. Feasibility and acceptability were quantitatively assessed using the Dissemination and Implementation Measures. Fidelity was assessed by rating all 100 audio-recorded sessions using a checklist. To obtain qualitative feedback on the intervention, we conducted five focus group discussions with 25 youths and six semi-structured interviews with two peer providers and four clinic leaders. The semi-structured interviews were guided by the Consolidated Framework for Implementation Research. Quantitative data was analyzed via descriptive statistics using STATA. Qualitative data was analyzed using thematic analysis with NVIVO.

RESULTS

The lifetime prevalence of any substance use was 50%. The mean level of acceptability of the intervention from the perspective of the youth was 3.53 (SD 0.15), meaning that the youth found the intervention to be acceptable "a lot" of the time. Mean levels of implementation outcomes (acceptability, adoption, Acceptability, Appropriateness, Feasibility, Reach/access, Organizational climate, General leadership skills, and Sustainability) as rated by peer providers and clinic staff ranged between 2.61 ("a moderate amount") and 4.0 ("a lot"). In qualitative data, youth reported that the intervention was helpful and useful in enabling them to stop or reduce substance use. The peer providers felt that the intervention was easy to implement, while the clinic leaders felt that available resources were adequate, and that the intervention aligned well with the goals of the clinic.

CONCLUSION

Our findings suggest that the peer-delivered screening and brief intervention program was perceived as acceptable to the youth and feasible to implement.

TRIAL REGISTRATION

NCT04998045 Registration date: 10/08/2021.

Gender considerations for supportive supervision in humanitarian contexts: A qualitative study

Supportive supervision has been shown to improve mental health outcomes and job retention for mental health and psychosocial support (MHPSS) workers in humanitarian contexts. However, the impact of gender on supervision practices has been poorly evaluated and documented in international guidelines to date. To address this gap, qualitative interviews were conducted with 12 MHPSS staff working in diverse humanitarian contexts to identify key gender considerations in supportive supervision. Results show that gender in supervision is influenced by the context of MHPSS work; with culture, religion and gender roles identified as key elements. Participants discuss recruitment mechanisms, highlighting the unequal gender distribution and inequitable opportunities within MHPSS programming. The importance of addressing power dynamics impacted by gender and of ensuring the safety of women within supervision is also highlighted. Finally, participants discuss the gender differences across the various supervisory formats. Altogether, results indicate that gender has the potential to influence supportive supervision within MHPSS, and it is recommended that international guidelines account for nuances of gender in supportive supervision within humanitarian contexts.