Advancing Gender Equality in Healthcare Leadership: Protocol to Co-Design and Evaluate a Leadership and Mentoring Intervention in Tanzania

Background

Women constitute almost two thirds of the health and social workforce. Yet, the proportion of women in decision-making positions remains significantly low leading to gender inequities in access to and appropriateness of healthcare. Several barriers which limit women's advancement to leadership positions have been documented and they generally constitute of gender stereotypes, discrimination and inhibiting systems; these hinderances are compounded by intersection with other social identities. Amelioration of the barriers has the potential to enhance women's participation in leadership and strengthen the existing health systems.

Objective

This protocol describes a proposed study aimed at addressing the organisational and individual barriers to the advancement of women to leadership positions in the Tanzanian health sector, and to evaluate the influence on leadership competencies and career advancement actions of the female health workforce.

Method

The study utilises a gender transformative approach, co-design and implementation science in the development and integration of a leadership and mentorship intervention for women in the Tanzanian health context. The key steps in this research include quantifying the gender ratio in healthcare leadership; identifying the individual and organisational barriers to women's leadership; reviewing existing leadership, mentorship and career advancement interventions for women; recruiting programme participants for a leadership and mentorship programme; running a co-design workshop with programme participants and stakeholders; implementing a leadership and mentorship programme; and conducting a collaborative evaluation and lessons learnt.

Conclusions

This research underscores the notion that progression towards gender equality in healthcare leadership is attained by fashioning a system that supports the advancement of women. We also argue that one of the pivotal indicators of progress towards the gender equality sustainable development goal is the number of women in senior and middle management positions, which we hope to further through this research.

Realist evaluation of maternity waiting home intervention models in Inhambane, Mozambique: protocol for a comparative embedded case study, the Mozambique-Canada Maternal Health Project

INTRODUCTION

This is a study protocol that tests and refines realist theories regarding the uptake and scale-up of the linked maternity waiting home (hereafter MWH) and facility birth intervention in the Mozambican context. The theories were developed through a realist review of MWH-facility birth literature from low-income and middle-income countries. The aim of the proposed study is to contribute to a contextually refined understanding of the causal chains underlying MWH-facility birth adoption by pregnant women and their families, communities, the health system and donors.

METHODS AND ANALYSIS

The overarching methodology is mixed-methods realist evaluation. The study will adopt a comparative embedded case study design comparing three new masonry MWHs built by the Mozambique-Canada Maternal Health Project in Inhambane province with three older MWHs selected based on variation in the built environment. Baseline data on participating MWH-facility birth interventions will be collected through observations, reviews of routine data and analysis of statistics and reports from provincial and district health authorities and the Mozambique-Canada Maternal Health project. Realist interviews will be conducted with MWH users and non-users, companions of MWH users and non-users, partners of MWH users and non-users, and stakeholders within the health system and the non-governmental organisation sector. Realist focus groups will be used to collect data from community-level implementers. The analysis will be retroductive and use the context-mechanism-outcome configuration heuristic tool to represent generative causation. We will analyse data from intervention and comparator MWHs independently and compare the resulting refined programme theories. Data analysis will be done in NVivo 12.

ETHICS AND DISSEMINATION

Ethics approval for the project has been obtained from the Mozambique National Bioethics Committee (CNBS-Comité Nacional de Bioética para a Saúde) and the University of Saskatchewan Bioethical Research Ethics Board. The evaluation will adhere to the International Ethical Guidelines for Biomedical Research Involving Human Subjects and the African adaptation of evaluation ethics and principles. Evaluation results will be disseminated to stakeholders' practice audiences through peer-reviewed publications, plain-language briefs, theory validation/feedback meetings and conference presentations.

Exploring the needs and experiences of contact tracing staff during the COVID-19 pandemic in Ireland

BACKGROUND

Contact tracing is a key component in controlling the spread of COVID-19, however little research has focused on learning from the experiences of contact tracing staff. Harnessing learning from those in this role can provide valuable insights into the process of contact tracing and how best to support staff in this crucial role.

METHODS

Thematic analysis was used to analyse 47 semi-structured interviews conducted with contact tracing staff via telephone or Zoom at three time points in 2021: March, May and September-October.

RESULTS

Six themes related to the contact tracing role were identified, including training, workforce culture, systems issues, motivation and support. While initially nervous in the role, participants were motivated to contribute to the pandemic response and believed the role provided them with valuable transferable skills. Participants described the training as having improved over time while desiring more proactive training. Sources of frustration included a perceived lack of opportunity for feedback and involvement in process changes, feelings of low autonomy, and a perception of high staff turnover. Participants expressed a need for improved communication of formal emotional supports. Increased managerial support and provision of opportunities for career advancement may contribute to increased motivation among staff.

CONCLUSIONS

These findings identify the experiences of contact tracing staff working during the COVID-19 pandemic, and have important implications for the improvement of the contact tracing system. Recommendations based on learning from participants offer suggestions as to how best to support the needs of contact tracing staff during a pandemic response.

Understanding communication in community engagement for maternal and newborn health programmes in low- and middle-income countries: a realist review

As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

A framework for community health worker optimisation in conflict settings: prerequisites and possibilities from Northwest Syria

BACKGROUND

The world will face a human resource gap of 10 million health workers in 2030. Community health workers (CHWs) can contribute to mitigating this workforce gap while improving equitable access to care and health outcomes. However, questions on how to best implement and optimise CHW programmes, especially across varied contexts, remain. As each context has its determinants for a successful CHW programme, this research identifies and assesses pertinent factors needed for optimal CHW programmes in conflict settings, specifically Northwest Syria.

METHODS

A mixed-methods study in Northwest Syria consisting of a literature and document review, semistructured interviews with CHWs' team leaders and programme managers, key informant interviews with policymakers and a survey with CHWs was conducted across three research phases from 2018 to 2022. The three phases aimed to identify, refine and finalise a framework for CHW optimisation in humanitarian conflict contexts, respectively. Qualitative data were analysed thematically, and quantitative data were statistically analysed to identify critical trends.

RESULTS

16 interviews and 288 surveys were conducted, supplemented by key reports and literature. The framework underwent two iterative rounds of refinement, reflecting varying stakeholders' perceptions of CHW optimisation. The resulting framework presents important implementation factors with subthemes across identified topics of institutionalisation, integration and representation for CHW optimisation in Northwest Syria and other humanitarian conflict contexts. The presented factors are similar in various ways to other fragile low/middle-income country settings. However, in protracted conflict settings like Syria, careful consideration should be given to strategic dimensions such as integration and representation.

CONCLUSION

For CHW programmes to impact health outcomes in humanitarian conflict settings, they require a set of implementation and design factors relevant to the context. The dynamics of humanitarian funding restrictions, health system capacity and governance structures confront achieving these requirements. Nevertheless, pioneering projects which use available resources are possible. Evidence is needed to understand the impact of CHWs' interventions and further support implementation across humanitarian contexts.

Exploring the psychological impact of contact tracing work on staff during the COVID-19 pandemic

BACKGROUND

Contact tracing is a key control measure in the response to the COVID-19 pandemic. While quantitative research has been conducted on the psychological impact of the pandemic on other frontline healthcare workers, none has explored the impact on contact tracing staff.

METHODS

A longitudinal study was conducted using two repeated measures with contact tracing staff employed in Ireland during the COVID-19 pandemic using two-tailed independent samples t tests and exploratory linear mixed models.

RESULTS

The study sample included 137 contact tracers in March 2021 (T1) and 218 in September 2021 (T3). There was an increase from T1 to T3 in burnout related exhaustion (p < 0·001), post-traumatic stress disorder (PTSD) symptom scores (p < 0·001), mental distress (p < 0·01), perceived stress (p < 0·001) and tension and pressure (p < 0·001). In those aged 18-30, there was an increase in exhaustion related burnout (p < 0·01), PTSD symptoms (p < 0·05), and tension and pressure scores (p < 0·05). Additionally, participants with a background in healthcare showed an increase in PTSD symptom scores by T3 (p < 0·001), reaching mean scores equivalent to those of participants who did not have a background in healthcare.

CONCLUSIONS

Contact tracing staff working during the COVID-19 pandemic experienced an increase in adverse psychological outcomes. These findings highlight a need for further research on psychological supports required by contact tracing staff with differing demographic profiles.

Applying and reporting relevance, richness and rigour in realist evidence appraisals: Advancing key concepts in realist reviews

The realist review/synthesis has become an increasingly prominent methodological approach to evidence synthesis that can inform policy and practice. While there are publication standards and guidelines for the conduct of realist reviews, published reviews often provide minimal detail regarding how they have conducted some methodological steps. This includes selecting and appraising evidence sources, which are often considered for their 'relevance, richness and rigour.' In contrast to other review approaches, for example, narrative reviews and meta-analyses, the inclusion criteria and appraisal of evidence within realist reviews depend less on the study's methodological quality and more on its contribution to our understanding of generative causation, uncovered through the process of retroductive theorising. This research brief aims to discuss the current challenges and practices for appraising documents' relevance, richness and rigour and to provide pragmatic suggestions for how realist reviewers can put this into practice.

Impact of COVID-19 on the private and professional lives of highly educated women working in global health in Europe-A qualitative study

Background

The COVID-19 pandemic has led to a deepening of existing inequalities and a rollback of achievements made in gender equality. Women in Global Health (WGH) is a global movement that aims to achieve gender equality in health and increase female leadership in global health. Here, the aim was to understand how the pandemic affects the private and professional lives of women working in global health in different European countries. Suggestions for future pandemic preparedness including how gender perspectives should be integrated into pandemic preparedness and how a women's network such as WGH helped them to overcome the impact of the pandemic were explored.

Methods

Qualitative semi-structured interviews were conducted in September 2020 with a sample size of nine highly educated women with a mean age of 42.1 years from the different WGH European chapters. The participants were informed of the study and were formally asked for their consent. The interviews were held in English via an online videoconference platform and lasted 20-25 min each. The interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted according to Mayring Qualitative Content Analysis using MAXQDA.

Results

The pandemic has both positive and negative effects on the professional and private lives of women. It led to an increased workload and stress as well as pressure to publish on COVID-19-related themes. Increased childcare and household responsibilities represented a double burden. The available space was limited if other family members were also working from home. Positive aspects included more time for family or partners and reduced travel. The participants report on perceived gender differences in the experience of the pandemic. International cooperation is considered to be a key factor for future pandemic preparedness. Being part of a women's network such as WGH was perceived as being very supportive in difficult situations during the pandemic.

Conclusion

This study provides unique insights into the experiences of women working in global health in different European countries. The COVID-19 pandemic influences their professional and private lives. Perceived gender differences are reported and suggest the need for integrating gender perspectives in pandemic preparedness. Networks for women, such as WGH, can facilitate the exchange of information in crises and provide women with professional and personal support.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Community engagement to support COVID-19 vaccine uptake: a living systematic review protocol

INTRODUCTION

Widespread vaccination against COVID-19 is one of the most effective ways to control, and ideally, end the global COVID-19 pandemic. Vaccine hesitancy and vaccine rates vary widely across countries and populations and are influenced by complex sociocultural, political, economic and psychological factors. Community engagement is an integral strategy within immunisation campaigns and has been shown to improve vaccine acceptance. As evidence on community engagement to support COVID-19 vaccine uptake is emerging and constantly changing, research that lessens the knowledge-to-practice gap by providing regular and up-to-date evidence on current best-practice is essential.

METHODS AND ANALYSIS

A living systematic review will be conducted which includes an initial systematic review and bimonthly review updates. Searching and screening for the review and subsequent updates will be done in four streams: a systematic search of six databases, grey literature review, preprint review and citizen sourcing. The screening will be done by a minimum of two reviewers at title/abstract and full-text in Covidence, a systematic review management software. Data will be extracted across predefined fields in an excel spreadsheet that includes information about article characteristics, context and population, community engagement approaches, and outcomes. Synthesis will occur using the convergent integrated approach. We will explore the potential to quantitatively synthesise primary outcomes depending on heterogeneity of the studies.

ETHICS AND DISSEMINATION

The initial review and subsequent bimonthly searches and their results will be disseminated transparently via open-access methods. Quarterly briefs will be shared on the reviews' social media platforms and across other interested networks and repositories. A dedicated web link will be created on the Community Health-Community of Practice site for sharing findings and obtaining feedback. A mailing list will be developed and interested parties can subscribe for updates.

PROSPERO REGISTRATION NUMBER

CRD42022301996.

A realist review protocol on communications for community engagement in maternal and newborn health programmes in low- and middle-income countries

BACKGROUND

Community engagement (CE) has been increasingly implemented across health interventions, including for maternal and newborn health (MNH). This may take various forms, from participatory women's groups and community health committees to public advocacy days. While research suggests a positive influence of CE on MNH outcomes, such as mortality or care-seeking behaviour, there is a need for further evidence on the processes of CE in different settings in order to inform the future development and implementation of CE across programmes. Communication is an integral component of CE serving as a link between the programme and community. The aim of the realist review described in this protocol is to understand how, why, to what extent, and for whom CE contributes to intended and unintended outcomes in MNH programming, focusing on the communication components of CE.

METHODS

Realist review methodology will be used to provide a causal understanding of what communication for CE interventions in MNH programming work, for whom, to what extent, why, and how. This will be done by developing and refining programme theories on communications for CE in MNH through a systematic review of the literature and engaging key experts for input and feedback. By extrapolating context-mechanism-outcome configurations, this review seeks to understand how certain contexts trigger or inhibit specific mechanisms and what outcomes this interaction generates when communication in CE interventions is used in MNH programming.

DISCUSSION

A realist philosophy is well-suited to address the aims of this study because of the complex nature of CE. The review findings will be used to inform a realist evaluation case study of CE for an MNH programme in order to ascertain transferable findings that can inform and guide engagement activities in various settings. Findings will also be shared with stakeholders and experts involved in the consultative processes of the review (through workshops or policy briefs) in order to ensure the relevance of these findings to policy and practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022293564.

Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis

Introduction

Maternity waiting homes (MWHs) link pregnant women to skilled birth attendance at health facilities. Research suggests that some MWH-facility birth interventions are more success at meeting the needs and expectations of their intended users than others. We aimed to develop theory regarding what resources work to support uptake and scale-up of MHW-facility birth interventions, how, for whom, in what contexts and why.

Methods

A four-step realist review was conducted which included development of an initial programme theory; searches for evidence; selection, appraisal and extraction of data; and analysis and data synthesis.

Results

A programme theory was developed from 106 secondary sources and 12 primary interviews with MWH implementers. The theory demonstrated that uptake and scale-up of the MWH-facility birth intervention depends on complex interactions between three adopter groups: health system stakeholders, community gatekeepers and pregnant women and their families. It describes relationships between 19 contexts, 11 mechanisms and 31 outcomes accross nine context-mechanism-outcome configurations (CMOCs) which were grouped into 3 themes: (1) Engaging stakeholders to develop, integrate, and sustain MWH-facility birth interventions, (2) Promoting and enabling MWH-facility birth utilisation and (3) Creating positive and memorable MWH-facility birth user experiences. Belief, trust, empowerment, health literacy and perceptions of safety, comfort and dignity were mechanisms that supported diffusion and adoption of the intervention within communities and health systems. Examples of resources provided by implementers to trigger mechanisms associated with each CMOC were identified.

Conclusions

Implementers of MWHs cannot merely assume that communities will collectively value an MWH-facility birth experience over delivery at home. We posit that MWH-facility birth interventions become vulnerable to under-utilisation when implementers fail to: (1) remove barriers that hinder women’s access to MWH and (2) ensure that conditions and interactions experienced within the MWH and its affiliated health facility support women to feel treated with compassion, dignity and respect.

PROSPERO registration number

CRD42020173595.

The role of psychosocial factors in explaining sex differences in major depression and generalized anxiety during the COVID-19 pandemic

Background

Understanding how pandemics differentially impact on the socio-protective and psychological outcomes of males and females is important to develop more equitable public health policies. We assessed whether males and females differed on measures of major depression and generalized anxiety during the COVID-19 the pandemic, and if so, which sociodemographic, pandemic, and psychological variables may affect sex differences in depression and anxiety.

Methods

Participants were a nationally representative sample of Irish adults (N = 1,032) assessed between April 30^th to May 19^th, 2020, during Ireland’s first COVID-19 nationwide quarantine. Participants completed self-report measures of anxiety (GAD-7) and depression (PHQ-9), as well as 23 sociodemographic pandemic-related, and psychological variables. Sex differences on measures of depression and anxiety were assessed using binary logistic regression analysis and differences in sociodemographic, pandemic, and psychological variables assessed using chi-square tests of independence and independent samples t-tests.

Results

Females were significantly more likely than males to screen positive for major depressive disorder (30.6% vs. 20.7%; χ² (1) = 13.26, p < .001, OR = 1.69 [95% CI = 1.27, 2.25]), and generalised anxiety disorder (23.3% vs. 14.4%; χ² (1) = 13.42, p < .001, OR = 1.81 [95% CI = 1.31, 2.49]). When adjusted for all other sex-varying covariates however, sex was no longer significantly associated with screening positive for depression (AOR = 0.80, 95% CI = 0.51, 1.25) or GAD (AOR = 0.97, 95% CI = 0.60, 1.57).

Conclusion

Observed sex-differences in depression and anxiety during the COVID-19 pandemic in the Republic of Ireland are best explained by psychosocial factors of COVID-19 related anxiety, trait neuroticism, lower sleep quality, higher levels of loneliness, greater somatic problems, and, in the case of depression, increases in childcaring responsibilities and lower trait consciousnesses. Implications of these findings for public health policy and interventions are discussed.

Sexual Violence and Its Associated Psychosocial Effects in Ireland

Current data on the prevalence and psychosocial correlates of sexual violence in the Republic of Ireland is lacking, with the most recent sexual abuse and violence survey dating back to 2001. The current study sought to identify what proportion of Irish adults have experienced sexual violence, if there are sex differences in exposure to different forms of sexual violence, and to what extent different forms of sexual violence are associated with adverse psychosocial outcomes. To achieve these objectives, we carried out a nationally representative sample of Irish adults (N = 1,020) completed self-report measures of history of sexual violence and mental health. Results suggest that approximately one-in-three (34.4%) Irish adults experienced some form of sexual violence, including 14.8% who were sexually assaulted (raped) and 31.1% who were sexually harassed. Women were significantly more likely than men to have experienced all forms of sexual violence (ps < .001), with the exception of sexual assault by a parent or guardian. All forms of sexual violence were associated with an increased likelihood of serious mental health problems, with sexual assault by a parent/guardian associated with several other psychosocial outcomes in life, including education achievement, history of being taken into state care, salary, and employment status. Sexual violence is a common experience in the general population and women are disproportionately affected (1-in-2 women versus 1-in-5 men). Additional resources to increase mental health care among survivors of sexual violence is urgently needed. How our findings compare to Ireland's previous sexual abuse and violence survey and the implications of our findings for policy are discussed.

Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: A review of reviews

Background

Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health.

Objective

To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC.

Methods

Six databases (MEDLINE, Embase, CINAHL, PsychINFO, Cochrane Library, PROSPERO) were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews.

Results

In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans.

Conclusions

While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts.

Evaluation of a formative peer assessment in research methods teaching using an online platform: A mixed methods pre-post study

BACKGROUND

In higher education settings, there are increasing calls to shift away from traditional summative assessment practices, such end of term written tests, to explore methods of assessing learning in alternative ways. Peer assessment has been advocated as a means of formative assessment to enhance student engagement, empowering students to take responsibility for their own learning. While there is accumulating evidence for the value of peer assessment in higher education, one cannot assume peer feedback will translate appropriately to all settings and educational contexts.

OBJECTIVES

This study evaluated the implementation of formative online peer assessment in a nursing and midwifery research methods module. We explored students' expectations, experiences, and ultimately the acceptability of this approach.

DESIGN

A quantitative descriptive study.

SETTING

Ireland.

METHODS

An online survey to collate expectations and experiences of engagement in peer assessment. Scales were drawn from previous research and non-parametric tests explored changes in perceptions over time. Qualitative content analysis explored patterns evident in open-text responses.

RESULTS

The response rate was 28% (n = 74) at baseline and 31% at follow-up (n = 81). Peer assessment was a new experience for 95% of respondents. Students initially expressed apprehension, perceiving the task as daunting, and doubting their ability to provide feedback to peers. However, through providing instruction and tools to support students in the activity, high levels of satisfaction with the process and the experience were reported. Significant differences in perceptions of peer assessment were evident over time, including an enhanced belief that respondents had the requisite skills to appraise the work of their peers.

CONCLUSIONS

In sum, nursing and midwifery students agreed that peer assessment was a valuable learning experience as part of research methods training and critical skills development.

Contact tracing during the COVID-19 outbreak: a protocol for enabling rapid learning from experiences and exploring the psychological impact on contact tracers

Background: Given the unprecedented nature of the COVID-19 pandemic, the Irish health system required the redeployment of public sector staff and the recruitment of dedicated contact tracing staff in the effort to contain the spread of the virus. Contact tracing is crucial for effective disease control and is normally carried out by public health teams. Contact tracing staff are provided with rapid intensive training but are operating in a dynamic environment where processes and advice are adapting continuously. Real-time data is essential to inform strategy, coordinate interconnected processes, and respond to needs . Given that many contact tracers have been newly recruited or redeployed, they may not have significant experience in healthcare and may experience difficulties in managing the anxieties and emotional distress of the public.

Aim: (i) identify emerging needs and issues and feed this information back to the Health Service Executive for updates to the COVID-19 Contact Management Programme (CMP); (ii) understand the psychological impact on contact tracers and inform the development of appropriate supports.

Methods: We will use a mixed-methods approach. A brief online survey will be administered at up to three time points during 2021 to measure emotional exhaustion, anxiety, general health, and stress of contact tracing staff, identify tracing systems or processes issues, as well as issues of concern and confusion among the public. Interviews will also be conducted with a subset of participants to achieve a more in-depth understanding of these experiences. Observations may be conducted in contact tracing centres to document processes, practices, and explore any local contextual issues.

Impact: Regular briefs arising from this research with data, analysis, and recommendations will aim to support the work of the CMP to identify problems and implement solutions. We will deliver regular feedback on systems issues; challenges; and the psychological well-being of contact tracing staff.

A mapping and synthesis of tools for stakeholder and community engagement in quality improvement initiatives for reproductive, maternal, newborn, child and adolescent health

BACKGROUND

Stakeholder and community engagement promotes collaboration and gives service users an opportunity to actively participate in the care they receive. Recognizing this potential, The Network for Improving Quality of Care for maternal, newborn and child health aimed to identify tools and operational guidance to integrate stakeholder and community engagement into quality improvement (QI) implementation.

METHODS

A mapping, consisting of a literature review and an open call through email and listservers, for implementation tools was conducted. Materials were included if they provided guidance on stakeholder and community engagement aligned to the Network's QI framework comprising seven phases. Screening of tools was done by two reviewers.

RESULTS

The literature search and the call for tools returned 197 documents with 70 tools included after screening. Most included tools (70%) were published after 2010. International organizations were the most frequently cited authors of tools. Only 15 tools covered all seven phases of the QI framework; few tools covered the more 'technical' phase of the QI framework: adapting standards and refining strategies.

CONCLUSION

The quantity of tools and their varied characteristics including types of stakeholder and community engagement processes across the QI framework confirms that engagement cannot be captured in a 'one-size-fits-all' formula. Many tools were designed with a generic focus to allow for adaption and use in different settings and sectors. Country programmes looking to strengthen engagement approaches can take advantage of available tools through an online portal on the WHO website and adapt them to meet their specific needs and context.

PUBLIC INVOLVEMENT

Programme implementers provided tools and resources during data collection.

Contact tracing during the COVID-19 outbreak: a protocol for enabling rapid learning from experiences and exploring the psychological impact on contact tracers

Background: Given the unprecedented nature of the COVID-19 pandemic, the Irish health system required the redeployment of public sector staff and the recruitment of dedicated contact tracing staff in the effort to contain the spread of the virus. Contact tracing is crucial for effective disease control and is normally carried out by public health teams. Contact tracing staff are provided with rapid intensive training but are operating in a dynamic environment where processes and advice are adapting continuously. Real-time data is essential to inform strategy, coordinate interconnected processes, and respond to needs. Given that many contact tracers have been newly recruited or redeployed, they may not have significant experience in healthcare and may experience difficulties in managing the anxieties and emotional distress of the public. Aim: (i) identify emerging needs and issues and feed this information back to the Health Service Executive for updates to the COVID-19 Contact Management Programme (CMP); (ii) understand the psychological impact on contact tracers and inform the development of appropriate supports. Methods: We will use a mixed-methods approach. A brief online survey will be administered at up to three time points during 2021 to measure emotional exhaustion, anxiety, general health, and stress of contact tracing staff, identify tracing systems or processes issues, as well as issues of concern and confusion among the public. Interviews will also be conducted with a subset of participants to achieve a more in-depth understanding of these experiences. Observations may be conducted in contact tracing centres to document processes, practices, and explore any local contextual issues. Impact: Regular briefs arising from this research with data, analysis, and recommendations will aim to support the work of the CMP to identify problems and implement solutions. We will deliver regular feedback on systems issues; challenges; and the psychological well-being of contact tracing staff.

A Rapid Realist Review of Group Psychological First Aid for Humanitarian Workers and Volunteers

Humanitarian workers are at an elevated risk of occupational trauma exposure and its associated psychological consequences, and experience increased levels of anxiety, depression, and post-traumatic stress disorder (PTSD) compared to the general population. Psychological first aid (PFA) aims to prevent acute distress reactions from developing into long-term distress by instilling feelings of safety, calmness, self- and community efficacy, connectedness and hope. Group PFA (GPFA) delivers PFA in a group or team setting. This research sought to understand 'What works, for whom, in what context, and why for group psychological first aid for humanitarian workers, including volunteers?' A rapid realist review (RRR) was conducted. Initial theories were generated to answer the question and were subsequently refined based on 15 documents identified through a systematic search of databases and grey literature, in addition to the inputs from a core reference panel and two external experts in GPFA. The findings generated seven programme theories that addressed the research question and offered consideration for the implementation of GPFA for the humanitarian workforce across contexts and age groups. GPFA enables individuals to understand their natural reactions, develop adaptive coping strategies, and build social connections that promote a sense of belonging and security. The integrated design of GPFA ensures that individuals are linked to additional supports and have their basic needs addressed. While the evidence is sparce on GPFA, its ability to provide support to humanitarian workers is promising.

What do we mean by individual capacity strengthening for primary health care in low- and middle-income countries? A systematic scoping review to improve conceptual clarity

BACKGROUND

Capacity strengthening of primary health care workers is widely used as a means to strengthen health service delivery, particularly in low- and middle-income countries. Despite the widespread recognition of the importance of capacity strengthening to improve access to quality health care, how the term 'capacity strengthening' is both used and measured varies substantially across the literature. This scoping review sought to identify the most common domains of individual capacity strengthening, as well as their most common forms of measurement, to generate a better understanding of what is meant by the term 'capacity strengthening' for primary health care workers.

METHODS

Six electronic databases were searched for studies published between January 2000 and October 2020. A total of 4474 articles were screened at title and abstract phase and 323 full-text articles were reviewed. 55 articles were ultimately identified for inclusion, covering various geographic settings and health topics.

RESULTS

Capacity strengthening is predominantly conceptualised in relation to knowledge and skills, as either sole domains of capacity, or used in combination with other domains including self-efficacy, practices, ability, and competencies. Capacity strengthening is primarily measured using pre- and post-tests, practical evaluations, and observation. These occur along study-specific indicators, though some pre-existing, validated tools are also used.

CONCLUSION

The concept of capacity strengthening for primary health care workers reflected across a number of relevant frameworks and theories differs from what is commonly seen in practice. A framework of individual capacity strengthening across intra-personal, inter-personal, and technical domains is proposed, as an initial step towards building a common consensus of individual capacity strengthening for future work.

Community engagement for COVID-19 prevention and control: a rapid evidence synthesis

INTRODUCTION

Community engagement has been considered a fundamental component of past outbreaks, such as Ebola. However, there is concern over the lack of involvement of communities and 'bottom-up' approaches used within COVID-19 responses thus far. Identifying how community engagement approaches have been used in past epidemics may support more robust implementation within the COVID-19 response.

METHODOLOGY

A rapid evidence review was conducted to identify how community engagement is used for infectious disease prevention and control during epidemics. Three databases were searched in addition to extensive snowballing for grey literature. Previous epidemics were limited to Ebola, Zika, SARS, Middle East respiratory syndromeand H1N1 since 2000. No restrictions were applied to study design or language.

RESULTS

From 1112 references identified, 32 articles met our inclusion criteria, which detail 37 initiatives. Six main community engagement actors were identified: local leaders, community and faith-based organisations, community groups, health facility committees, individuals and key stakeholders. These worked on different functions: designing and planning, community entry and trust building, social and behaviour change communication, risk communication, surveillance and tracing, and logistics and administration.

CONCLUSION

COVID-19's global presence and social transmission pathways require social and community responses. This may be particularly important to reach marginalised populations and to support equity-informed responses. Aligning previous community engagement experience with current COVID-19 community-based strategy recommendations highlights how communities can play important and active roles in prevention and control. Countries worldwide are encouraged to assess existing community engagement structures and use community engagement approaches to support contextually specific, acceptable and appropriate COVID-19 prevention and control measures.

Community engagement for COVID-19 prevention and control: a rapid evidence synthesis

INTRODUCTION

Community engagement has been considered a fundamental component of past outbreaks, such as Ebola. However, there is concern over the lack of involvement of communities and 'bottom-up' approaches used within COVID-19 responses thus far. Identifying how community engagement approaches have been used in past epidemics may support more robust implementation within the COVID-19 response.

METHODOLOGY

A rapid evidence review was conducted to identify how community engagement is used for infectious disease prevention and control during epidemics. Three databases were searched in addition to extensive snowballing for grey literature. Previous epidemics were limited to Ebola, Zika, SARS, Middle East respiratory syndromeand H1N1 since 2000. No restrictions were applied to study design or language.

RESULTS

From 1112 references identified, 32 articles met our inclusion criteria, which detail 37 initiatives. Six main community engagement actors were identified: local leaders, community and faith-based organisations, community groups, health facility committees, individuals and key stakeholders. These worked on different functions: designing and planning, community entry and trust building, social and behaviour change communication, risk communication, surveillance and tracing, and logistics and administration.

CONCLUSION

COVID-19's global presence and social transmission pathways require social and community responses. This may be particularly important to reach marginalised populations and to support equity-informed responses. Aligning previous community engagement experience with current COVID-19 community-based strategy recommendations highlights how communities can play important and active roles in prevention and control. Countries worldwide are encouraged to assess existing community engagement structures and use community engagement approaches to support contextually specific, acceptable and appropriate COVID-19 prevention and control measures.

Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries

BACKGROUND

Close-to-community (CTC) health service providers are a cost-effective and important resource in the promotion of and increasing access to health services. However, many CTC provider programmes suffer from high rates of de-motivation and attrition due to inadequate support systems. Recent literature has identified the lack of rigorous approaches towards measuring and monitoring motivation among CTC providers as an important gap. Building on scales used in previous studies, we set out to develop a short, simple-to-administer scale to monitor and measure indicators of CTC provider motivation across CTC programmes implemented in six countries: Ethiopia, Kenya, Malawi, Mozambique, Indonesia, and Bangladesh.

METHODS

We used focus group discussions (n = 18) and interviews (n = 106) conducted with CTC providers across all six countries, applying thematic analysis techniques to identify key determinants of motivation across these contexts. These themes were then used to carry out a systematic search of the literature, to identify existing scales or questionnaires developed for the measurement of these themes. A composite 24-item scale was then administered to CTC providers (n = 695) across the six countries. Survey responses were subsequently randomly assigned to one of two datasets: the first for scale refinement, using exploratory techniques, and the second for factorial validation. Confirmatory factor analysis was applied to both datasets.

RESULTS

Results suggest a 12-item, four-factor structure, measuring community commitment, organisational commitment, job satisfaction, and work conscientiousness as common indicators of motivation among CTC providers across the six countries.

CONCLUSIONS

Consistent with previous studies, findings support the inclusion of job satisfaction, organisational commitment, and work conscientiousness within the CTC Provider Motivation Indicator Scale. In addition, findings further supported the addition of a fourth, community commitment, sub-scale. Practical applications of the revised scale, including how it can be applied to monitor motivation levels within CTC provider programming, are discussed.

Realist evaluations in low- and middle-income countries: reflections and recommendations from the experiences of a foreign researcher

Realist evaluation, a methodology for exploring generative causation within complex health interventions to understand 'how, why and for whom' programmes work, is experiencing a surge of interest. Trends indicate that the proliferation in the use of this methodology also applies to research in low- and middle-income countries (LMICs). The value of using realist evaluation for project evaluation is also being noticed by non-governmental organisations (NGOs) and other programme implementers within such contexts. Yet, there is limited exploration of the use of realist evaluations in LMICs, especially their use by foreign researchers. This paper draws on the author's experience of conducting two realist evaluations across three different sub-Saharan African settings: Mundemu, Tanzania; Kabale, Uganda and Marsabit, Kenya. The realist evaluations were used as an operations research methodology to study two NGO community health programmes. This paper highlights four main challenges experienced by the author throughout the methodological process: (1) power imbalances prevalent during realist interviews, (2) working through translation and what this means for identfying Context-Mechanism-Outcome Configurations, (3) limited contextual familiarity and being an 'engaged researcher' and (4) the use or dependence on 'WEIRD' theories (i.e. theories based on the study of Western, Educated, Industrialized, Rich, Democratic people) within testing and refinement. Realist evaluation's enticing and straightforward slogan of finding 'what works, for whom and why' is in contrast to the complexity of the methodology used to generate these results (and often to the results themselves). Striking a balance between theory and pragmatism, while adhering to realist ontological underpinnings of generative causation and retroduction, is no easy task. This paper concludes by providing concrete recommendations for those who want to undertake a realist evaluation, with particular attention to cross-cultural settings, in light of the aforementioned challenges. In doing so, it aims to foster improved methodological rigour and help those engaging in this research methodology to work towards more appropriate and contextually relevant findings.

Adapting health interventions for local fit when scaling-up: a realist review protocol

INTRODUCTION

Scaling-up is essential to ensure universal access of effective health interventions. Scaling-up is a complex process, which occurs across diverse systems and contexts with no one-size-fits-all approach. To date, little attention has been paid to the process of scaling-up in how to make adaptations for local fit. The aim of this research is to develop theory on what actions can be used to make adaptations to health interventions for local fit when scaling-up across diverse contexts that will have practical application for implementers involved in scaling-up.

METHODS AND ANALYSIS

Given the complexity of this subject, a realist review methodology was selected. Specifically, realist review emphasises an iterative, non-linear process, whereby the review is refined as it progresses. The identification of how the context may activate mechanisms to achieve outcomes is used to generate theories on what works for whom in what circumstances. This protocol will describe the first completed stage of development of an initial programme theory framework, which identified potential actions, contexts, mechanisms and outcomes that could be used to make adaptations when scaling-up. It will then outline the methods for future stages of the review which will focus on identifying case examples of scale-up and adaptation in practice. This realist review consists of six stages: (i) clarifying scope and development of a theoretical framework, (ii) developing a search strategy, (iii) selection and appraisal, (iv) data extraction, (v) data synthesis and analysis and (vi) further theory refinement with stakeholders.

ETHICS AND DISSEMINATION

This review will develop theory on how adaptations can be made when scaling-up. Findings will be disseminated in a peer-reviewed journal and through stakeholder engagement as part of the research process. Ethical approval has been received through Health Policy and Management/Centre for Global Health Research Ethics Committee of Trinity College Dublin.

ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire

OBJECTIVE

Support for ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing; however, few studies include refugees or examine the clinical utility of PTSD/CPTSD classifications. This study sought to provide the first evaluations of (i) the factor structure of ICD-11 PTSD/CPTSD amongst refugees in the Middle East; and (ii) the clinical utility of the International Trauma Questionnaire (ITQ) to identify PTSD/CPTSD in a humanitarian context.

METHOD

Participants were 112 treatment-seeking Syrian refugees living in Lebanon. Factorial validity was assessed using confirmatory factor analysis (CFA) based on responses to the ITQ. Clinical utility of the ITQ was assessed through semi-structured interviews with six Lebanese psychotherapists.

RESULTS

Complex PTSD (36.1%) was more common than PTSD (25.2%), and no sex or age differences were observed at the prevalence or symptomatic levels. CFA results supported a two-factor higher-order model consistent with ICD-11 PTSD/CPTSD. Qualitative findings indicated that the ITQ is generally positively regarded, with some limitations and suggested modifications noted.

CONCLUSION

This is the first study to support the ICD-11 PTSD/CPTSD amongst refugees in the Middle East and the clinical utility of the ITQ in a humanitarian context. Findings support the growing evidence for the cross-cultural applicability of ICD-11 PTSD/CPTSD.

Opportunities for human resources for health and rehabilitation: a response to Jesus et al

We welcome Jesus et al.'s paper, which makes an important contribution to the under-researched area of the physical rehabilitation workforce. The authors present recommendations to "advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs" (p. 1). We argue that their perspective could however be strengthened by adopting a stronger global perspective, including consideration of the needs of low-resource settings. In particular, we highlight the integral role of more effective sector and inter-sectoral governance, the opportunity to support the development of community-based rehabilitation (CBR), the lessons that can be learnt from human resources for health (HRH) research and practice more generally, and the recent developments in the global provision of assistive technologies. Each of these issues has important implications and contributions to make to advance the policy and research agenda for the global rehabilitation workforce.

A study of human resource competencies required to implement community rehabilitation in less resourced settings

BACKGROUND

It is estimated that over one billion persons worldwide have some form of disability. However, there is lack of knowledge and prioritisation of how to serve the needs and provide opportunities for people with disabilities. The community-based rehabilitation (CBR) guidelines, with sufficient and sustained support, can assist in providing access to rehabilitation services, especially in less resourced settings with low resources for rehabilitation. In line with strengthening the implementation of the health-related CBR guidelines, this study aimed to determine what workforce characteristics at the community level enable quality rehabilitation services, with a focus primarily on less resourced settings.

METHODOLOGY

This was a two-phase review study using (1) a relevant literature review informed by realist synthesis methodology and (2) Delphi survey of the opinions of relevant stakeholders regarding the findings of the review. It focused on individuals (health professionals, lay health workers, community rehabilitation workers) providing services for persons with disabilities in less resourced settings.

RESULTS

Thirty-three articles were included in this review. Three Delphi iterations with 19 participants were completed. Taken together, these produced 33 recommendations for developing health-related rehabilitation services. Several general principles for configuring the community rehabilitation workforce emerged: community-based initiatives can allow services to reach more vulnerable populations; the need for supportive and structured supervision at the facility level; core skills likely include case management, social protection, monitoring and record keeping, counselling skills and mechanisms for referral; community ownership; training in CBR matrix and advocacy; a tiered/teamwork system of service delivery; and training should take a rights-based approach, include practical components, and involve persons with disabilities in the delivery and planning.

CONCLUSION

This research can contribute to implementing the WHO guidelines on the interaction between the health sector and CBR, particularly in the context of the Framework for Action for Strengthening Health Systems, in which human resources is one of six components. Realist syntheses can provide policy makers with detailed and practical information regarding complex health interventions, which may be valuable when planning and implementing programmes.

How do community health committees contribute to capacity building for maternal and child health? A realist evaluation protocol

INTRODUCTION

The proposed research is part of ongoing operations research within World Vision's Access: Infant and Maternal Health Programme. This study aims to identify key context features and underlying mechanisms through which community health committees build community capacity within the field of maternal and child health. This may help to improve programme implementation by providing contextually informed and explanatory findings for how community health committees work, what works best and for whom do they work for best for. Though frequently used within health programmes, little research is carried out on such committees' contribution to capacity building-a frequent goal or proposed outcome of these groups.

METHODS AND ANALYSIS

The scarce information that does exist often fails to explain 'how, why, and for whom' these committees work best. Since such groups typically operate within or as components of complex health interventions, they require a systems thinking approach and design, and thus so too does their evaluation. Using a mixed methods realist evaluation with intraprogramme case studies, this protocol details a proposed study on community health committees in rural Tanzania and Uganda to better understand underlying mechanisms through which these groups work (or do not) to build community capacity for maternal and child health. This research protocol follows the realist evaluation methodology of eliciting initial programme theories, to inform the field study design, which are detailed within. Thus far, the methodology of a realist evaluation has been well suited to the study of community health committees within these contexts. Implications for its use within these contexts are discussed within.

ETHICS AND DISSEMINATION

Institutional Review Boards and the appropriate research clearance bodies within Ireland, Uganda and Tanzania have approved this study. Planned dissemination activities include via academic and programme channels, as well as feedback to the communities in which this work occurs.

Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis

Background

Good governance may result in strengthened performance of a health system. Coherent policies are essential for good health system governance. The overall aim of this research is to provide the best available scientific evidence on principles of good policy related leadership and governance of health related rehabilitation services in less resourced settings. This research was also conducted to support development of the World Health Organization’s (WHO) Guidelines on health related rehabilitation.

Methods

An innovative study design was used, comprising two methods: a systematic search and realist synthesis of literature, and a Delphi survey of expert stakeholders to refine and triangulate findings from the realist synthesis. In accordance with Pawson and Tilley’s approach to realist synthesis, we identified context mechanism outcome pattern configurations (CMOCs) from the literature. Subsequently, these CMOCs were developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation.

Results

Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes to improve programme responsiveness, efficiency, effectiveness, and sustainability, and to strengthen service-user self-determination and satisfaction; collection of disaggregated disability statistics to support political momentum, decision-making of policymakers, evaluation, accountability, and equitable allocation of resources; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users to support equitable and accessible services; robust inter-sectoral coordination to cultivate coherent mandates across governmental departments regarding service provision; and ‘institutionalizing’ programmes by aligning them with preexisting Ministerial models of healthcare to support programme sustainability.

Conclusions

Alongside national policymakers, our policy recommendations are relevant for several stakeholders, including service providers and service-users. This research aims to provide broad policy recommendations, rather than a strict formula, in acknowledgement of contextual diversity and complexity. Accordingly, our study proposes general principles regarding optimal policy related governance of health related rehabilitation in less resourced settings, which may be valuable across diverse health systems and contexts.

Improving the performance of community health workers in humanitarian emergencies: a realist evaluation protocol for the PIECES programme

INTRODUCTION

Understanding what enhances the motivation and performance of community health workers (CHWs) in humanitarian emergencies represents a key research gap within the field of human resources for health. This paper presents the research protocol for the Performance ImprovEment of CHWs in Emergency Settings (PIECES) research programme. Enhancing Learning and Research in Humanitarian Action (ELRHA) funded the development of this protocol as part of their Health in Humanitarian Crises (R2HC) call (No.19839). PIECES aims to understand what factors improve the performance of CHWs in level III humanitarian emergencies.

METHODS AND ANALYSIS

The suggested protocol uses a realist evaluation with multiple cases across the 3 country sites: Turkey, Iraq and Lebanon. Working with International Medical Corps (IMC), an initial programme theory was elicited through literature and document reviews, semistructured interviews and focus groups with IMC programme managers and CHWs. Based on this initial theory, this protocol proposes a combination of semistructured interviews, life histories and critical incident narratives, surveys and latent variable modelling of key constructs to explain how contextual factors work to trigger mechanisms for specific outcomes relating to IMC's 300+ CHWs' performance. Participants will also include programme staff, CHWs and programme beneficiaries. Realist approaches will be used to better understand 'what works, for whom and under what conditions' for improving CHW performance within humanitarian contexts.

ETHICS AND DISSEMINATION

Trinity College Dublin's Health Policy and Management/Centre for Global Health Research Ethics Committee gave ethical approval for the protocol development phase. For the full research project, additional ethical approval will be sought from: Université St. Joseph (Lebanon), the Ethics Committee of the Ministry of Health in Baghdad (Iraq) and the Middle East Technical University (Turkey). Dissemination activities will involve a mixture of research feedback, policy briefs, guidelines and recommendations, as well as open source academic articles.

Can Sierra Leone maintain the equitable delivery of their Free Health Care Initiative? The case for more contextualised interventions: results of a cross-sectional survey

BACKGROUND

In 2010, the Ministry of Health and Sanitation in Sierra Leone launched their Free Health Care Initiative (FHCI) for pregnant and lactating mothers and children under-5. Despite an increase in the update of services, the inequitable distribution of health services and health facilities remain important factors underlying the poor performance of health systems to deliver effective services. This study identifies current gaps in service delivery across two rural locations served by the same District Health Management Team (DHMT).

METHODS

We employed a cross-sectional household survey using a two-stage probability sampling method to obtain a sample of the population across two rural locations in Bonthe District: the riverine and the mainland. Overall, a total of 393 households across 121 villages were surveyed in the riverine and 397 households across 130 villages were sampled on the mainland. Maternal health, child health and sanitation indicators in Bonthe District were compared using Pearson Chi-Squared test with Yates' Continuity Correction across the two areas.

RESULTS

Women across the two regions self-reported significantly different uptake of family planning services. Children on the mainland had significantly greater rates of health facility based deliveries; being born in the presence of a skilled birth attendant; completed immunisation schedules; and higher rates of being brought to the health centre within 24 h of developing a fever or a suspected acute respiratory infection. Households on the mainland also reported significantly greater use of treated water and unrestricted access to a latrine.

CONCLUSIONS

If the government of Sierra Leone is going to deliver on their promise to free health care for pregnant women and their children, and do so in a way that reduces inequalities, greater attention must be paid to the existing service delivery gaps within each District. This is particularly relevant to health policy post-Ebola, as it highlights the need for more contextualised service delivery to ensure equitable access for women and children.

The last one heard: the importance of an early-stage participatory evaluation for programme implementation

BACKGROUND

The systematic involvement of project beneficiaries in community maternal and child health programmes remains low and limited, especially during the formative stages of the project cycle. Understanding how positive and negative feedbacks obtained from communities can subsequently be used to inform and iterate existing programmes is an important step towards ensuring the success of community health workers for maternal and child health programming and, ultimately, for improving health outcomes.

METHODS

The study took place over a period of 4 weeks in North Rukiga, Kabale District of southwestern Uganda. Using a cross-sectional qualitative study that employed an epistemological approach of phenomenology, nine focus group discussions and eight in-depth interviews were conducted with a total of 76 female participants across six different sites. Women were identified as either users or non-users of the maternal and child health programme. Purposeful sampling was employed to recruit women from six different locations within the programme catchment area. Translated and transcribed transcripts were subjected to a bottom-up thematic analysis using NVivo 10 Software, whereby themes were arrived at inductively.

RESULTS

Predominant themes emerging from the focus groups and key informant interviews identified early trends in programme strengths. Beneficiaries reported confidence in both the programme and the relationships they had forged with community health workers, exhibited pride in the knowledge they had received, and described improved spousal involvement. Beneficiaries also identified a number of programme challenges including barriers to adopting the behaviours promoted by the programme, and highlighted issues with programme dependency and perceived ownership. It also emerged that community health workers were not reaching the entire population of intended programme beneficiaries.

CONCLUSIONS

This research provides support for the importance of an early-stage participatory evaluation of beneficiaries' perceptions of newly initiated health programmes. Our results support how evaluations conducted in the early phases of programme implementation can provide valuable, timely feedback as well as yield recommendations for programme adjustment or re-alignment, and in turn, better meet end-user expectations. Potential reasons for the observed lack of community participation in early stages of programme implementation are considered.

Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review

BACKGROUND

Community Health Workers are widely utilised in low- and middle-income countries and may be an important tool in reducing maternal and child mortality; however, evidence is lacking on their effectiveness for specific types of programmes, specifically programmes of a preventive nature. This review reports findings on a systematic review analysing effectiveness of preventive interventions delivered by Community Health Workers for Maternal and Child Health in low- and middle-income countries.

METHODS

A search strategy was developed according to the Evidence for Policy and Practice Information and Co-ordinating Centre's (EPPI-Centre) guidelines and systematic searching of the following databases occurred between June 8-11th, 2012: CINAHL, Embase, Ovid Nursing Database, PubMed, Scopus, Web of Science and POPLINE. Google, Google Scholar and WHO search engines, as well as relevant systematic reviews and reference lists from included articles were also searched. Inclusion criteria were: i) Target beneficiaries should be pregnant or recently pregnant women and/or children under-5 and/or caregivers of children under-5; ii) Interventions were required to be preventive and delivered by Community Health Workers at the household level. No exclusion criteria were stipulated for comparisons/controls or outcomes. Study characteristics of included articles were extracted using a data sheet and a peer tested quality assessment. A narrative synthesis of included studies was compiled with articles being coded descriptively to synthesise results and draw conclusions.

RESULTS

A total of 10,281 studies were initially identified and through the screening process a total of 17 articles detailing 19 studies were included in the review. Studies came from ten different countries and consisted of randomized controlled trials, cluster randomized controlled trials, before and after, case control and cross sectional studies. Overall quality of evidence was found to be moderate. Five main preventive intervention categories emerged: malaria prevention, health education, breastfeeding promotion, essential newborn care and psychosocial support. All categories showed some evidence for the effectiveness of Community Health Workers; however they were found to be especially effective in promoting mother-performed strategies (skin to skin care and exclusive breastfeeding).

CONCLUSIONS

Community Health Workers were shown to provide a range of preventive interventions for Maternal and Child Health in low- and middle-income countries with some evidence of effective strategies, though insufficient evidence is available to draw conclusions for most interventions and further research is needed.

Serial bedside emergency ultrasound in a case of pediatric blunt abdominal trauma with severe abdominal pain

We present a case of a teenager with isolated left renal laceration with perirenal hematoma. The patient had presented with severe left upper quadrant (LUQ) pain following blunt abdominal trauma (BAT) sustained during a sledding accident. A screening bedside focused abdominal sonogram for trauma (FAST) rapidly excluded free fluid on two serial examinations, 30 minutes apart. It provided the pediatric emergency physician with a measure of diagnostic confidence that the patient could be safely transported to the CT suite for detailed delineation of his injury. Moreover, narcotic analgesia was liberally administered early in his illness course, without the fear of unmasking potential hypovolemia when it was known that he did not have gross intra-abdominal bleeding on his bedside ultrasound (US). It also provided a working diagnosis of the primary organ of injury. Our hospital, like many pediatric hospitals around the nation, does not have in-house 24-hour radiology support. We suggest that the use of the bedside US be extended to the stable pediatric patient in severe abdominal pain following BAT. It can serve as a valuable, rapid, noninvasive, bedside, easily repeated, fairly accurate triage tool to evaluate pediatric BAT with severe pain.

Determination of systolic blood pressure via pulse oximeter in transported pediatric patients

OBJECTIVE

To compare pulse oximetry waveform systolic blood pressure measurements (POWSBP) to measurements obtained by noninvasive blood pressure measurement (NIBPM) during the transport of children.

DESIGN

A prospective, convenience sample.

SETTING AND PARTICIPANTS

All patients transported by a dedicated Pediatric Critical Care Transport Team were eligible for inclusion. Senior transport nurses with over 3 years of transport experience who had been instructed by the principal investigator (PI) in the technique, obtained the measurements and recorded the results. A convenience sample was obtained based on the presence or absence of one of the senior nurses on the transport team.

METHODS

Measurements of blood pressure were obtained by POWSBP and NIBPM (PROPAQ@; Protocol Systems, Beaverton, OR) on pediatric patients during transport in moving ambulances or fixed wing aircraft. Measurement of systolic blood pressure by pulse oximetry (POWSBP) was obtained on all patients by observing the return of the plethysmographic waveform of the pulse oximeter as the blood pressure cuff deflated. The patients were divided into two groups; in group A POWSBP measurements were obtained by using the automated BP cuff from the PROPAQ@ and in group B by a manual BP cuff. These measurements were compared to NIBPM readings obtained at the same time. Between 3 and 13 paired readings were obtained for each patient. The actual transport time determined the number of measurements obtained.

RESULTS

A total of 24 patients were enrolled in the study. Multiple matched pair readings (both POWSBP and NIBPM) were obtained from each patient for a total of 180 data points. A two variable linear regression model was run which identified a significant correlation between POWSBP and NIBPM. Group A, r = 0.7592 and r = 0.9477 for group B significant at P< 0.000001. Further, a corrective equation was developed for use with an automated BP cuff.

CONCLUSIONS

The use of pulse oximetry waveform systolic blood pressure measurement is a quick and easy method with which to obtain systolic blood pressure in children during transport and shows a close correlation to the standard noninvasive blood pressure measurement. If an automated blood pressure cuff is used, then a corrective equation [NIBP-S = 41.686 + 0.7377(POBPS)] is required. Further validation in a larger group of patients is recommended.

Proficiency test performance and experience with College of American Pathologists' programs

We examined rates of unacceptable results in a large interlaboratory proficiency test program, which is designed for small hospitals, clinics, and physician offices. The objective was to see whether rates of unacceptable results decrease as laboratories gain experience in interlaboratory comparison programs. We examined data from the College of American Pathologists' Excel Surveys, 1987 through 1993, in the areas of chemistry, hematology, immunology, and blood bank. The data for laboratories with consistent participation show consistent and statistically significant improvement in performance for the first 3 to 4 years of proficiency testing. The data for all participants also suggest that laboratories with more experience with proficiency testing have lower rates of unacceptable results, and that these rates tend to decrease with each year of experience. These conclusions support the findings of other researchers who have documented the benefits of interlaboratory comparison programs and proficiency testing.

An investigation of the magnitude and causes of count loss artifacts in SPECT imaging

A quantitative evaluation and an investigation of the mechanism of the count losses that can occur in SPECT imaging is described. The most common clinical example of the artifacts which result from this is encountered when sections are taken through the femoral heads in skeletal studies of the pelvis. From some simple phantom studies, it was identified that the count losses were associated with the presence of a high dynamic range in the projection data. Further information was obtained from simulation studies. It was found that the count loss phenomenon is caused by the combined effects of the presence of a high count density area and a structure with a relatively high attenuation level. An appreciation of the presence, magnitude, and mechanism of this effect is important if erroneous clinical findings are to be avoided. This is particularly relevant because of the existence of a variety of techniques that can be used to remove the resulting artifacts.

College of American Pathologists-Centers for Disease Control collaborative study for evaluating reference materials for total serum cholesterol measurements

Several recent studies to evaluate the performance of laboratory instruments have shown that with some instrument systems processed (lyophilized, frozen, and stabilized) materials exhibit matrix effects that cause the assay for cholesterol to respond differently for them than for patient specimens. To understand this phenomenon better the College of American Pathologists, Northfield, III, and the Centers for Disease Control, Atlanta, Ga, have conducted a collaborative study with 44 laboratories where 16 instruments manufactured by nine companies are evaluated. The purposes were to assess measurement variation on several reference materials used for standardizing total cholesterol measurements and to evaluate a new stabilized liquid serum as a potential reference material. Lypophilized, frozen, fresh-frozen, and stabilized materials at three concentrations were measured for total cholesterol. The results show that the average coefficient of variation of measured total cholesterol for all instruments, laboratories, vials, and replicates is 3.6% to 4.1% for each of the materials measured (excluding the results for one instrument). For one instrument, however, significant bias was found on the stabilized liquid serum material. Results from the fresh-frozen materials indicate that the instrument systems evaluated allow laboratories to attain the National Cholesterol Education Program analytical performance goals.

Supraglottitis in young adults

Supraglottitis is a disorder with the potential for significant morbidity and mortality in adults. Of the 25 patients we reviewed, 18 were black, representing the largest series of black adults with this condition reported in the medical literature. The mean age for black men was 14 years younger than previously described adults with supraglottitis. The index of suspicion for supraglottitis should be high in young adults with odynophagia out of proportion to findings on oropharyngeal examination. Indirect laryngoscopy will confirm the diagnosis and allow prompt initiation of treatment. Early recognition and treatment will avoid complications.

Quality control of agar diffusion susceptibility tests: data from the Quality Assurance Service Microbiology program of the College of American Pathologists

Over a 12-month period, between July 1981 and June 1982, 115 active participants in the Microbiology program of the College of American Pathologists Quality Assurance Service (QAS) submitted a total of 555,619 individual determinations on three quality control reference strains using the NCCLS standardized disc diffusion procedure. Data is presented for those antimicrobic agent/reference strain combinations for which NCCLS control limits have been changed since the last report of QAS microbiology data or that continue to show discrepancies with current NCCLS individual daily test control guidelines. Data for Escherichia coli versus cefoxitin, doxycycline, and nalidixic acid and for Staphylococcus aureus versus cefoxitin, nafcillin, and oxacillin show good compliance with the new NCCLS guidelines and distributions that are all approximately Gaussian. Significant discrepancies were noted for six combinations; cefamandole, cephalothin, neomycin, and nitrofurantoin versus E. coli and amikacin and clindamycin versus S. aureus. Of these discrepancies, only neomycin/E. coli and amikacin/S. aureus can be accounted for by a subpopulation of laboratories, which, when removed, corrects the data.