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Alhassan Y, Otiso L, Okoth L, Murray L, Hemingway C, Lewis JM, Oguche M, Doyle V, Muturi N, Ogwang E, Barsosio HC, Taegtmeyer M. Four antenatal care visits by four months of pregnancy and four vital tests for pregnant mothers: impact of a community-facility health systems strengthening intervention in Migori County, Kenya. BMC Pregnancy Childbirth 2024; 24:224. [PMID: 38539129 PMCID: PMC10967157 DOI: 10.1186/s12884-024-06386-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/01/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Early attendance at antenatal care (ANC), coupled with good-quality care, is essential for improving maternal and child health outcomes. However, achieving these outcomes in sub-Saharan Africa remains a challenge. This study examines the effects of a community-facility health system strengthening model (known as 4byFour) on early ANC attendance, testing for four conditions by four months of pregnancy, and four ANC clinic visits in Migori county, western Kenya. METHODS We conducted a mixed methods quasi-experimental study with a before-after interventional design to assess the impact of the 4byFour model on ANC attendance. Data were collected between August 2019 and December 2020 from two ANC hospitals. Using quantitative data obtained from facility ANC registers, we analysed 707 baseline and 894 endline unique ANC numbers (attendances) based on negative binomial regression. Logistic regression models were used to determine the impact of patient factors on outcomes with Akaike Information Criterion (AIC) and likelihood ratio testing used to compare models. Regular facility stock checks were undertaken at the study sites to assess the availability of ANC profile tests. Analysis of the quantitative data was conducted in R v4.1.1 software. Additionally, qualitative in-depth interviews were conducted with 37 purposively sampled participants, including pregnant mothers, community health volunteers, facility staff, and senior county health officials to explore outcomes of the intervention. The interview data were audio-recorded, transcribed, and coded; and thematic analysis was conducted in NVivo. RESULTS There was a significant 26% increase in overall ANC uptake in both facilities following the intervention. Early ANC attendance improved for all age groups, including adolescents, from 22% (baseline) to 33% (endline, p = 0.002). Logistic regression models predicting early booking were a better fit to data when patient factors were included (age, parity, and distance to clinic, p = 0.004 on likelihood ratio testing), suggesting that patient factors were associated with early booking.The proportion of women receiving all four tests by four months increased to 3% (27/894), with haemoglobin and malaria testing rates rising to 8% and 4%, respectively. Despite statistical significance (p < 0.001), the rates of testing remained low. Testing uptake in ANC was hampered by frequent shortage of profile commodities not covered by buffer stock and low ANC attendance during the first trimester. Qualitative data highlighted how community health volunteer-enhanced health education improved understanding and motivated early ANC-seeking. Community pregnancy testing facilitated early detection and referral, particularly for adolescent mothers. Challenges to optimal ANC attendance included insufficient knowledge about the ideal timing for ANC initiation, financial constraints, and long distances to facilities. CONCLUSION The 4byFour model of community-facility health system strengthening has the potential to improve early uptake of ANC and testing in pregnancy. Sustained improvement in ANC attendance requires concerted efforts to improve care quality, consistent availability of ANC commodities, understand motivating factors, and addressing barriers to ANC. Research involving randomised control trials is needed to strengthen the evidence on the model's effectiveness and inform potential scale up.
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Affiliation(s)
- Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Lilian Otiso
- LVCT Health, Sonning Suites, Suna Road off Ngong Rd, Adams Arcade, P.O. Box 19835, Nairobi, Kenya
| | - Linet Okoth
- LVCT Health, Sonning Suites, Suna Road off Ngong Rd, Adams Arcade, P.O. Box 19835, Nairobi, Kenya
| | - Lois Murray
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Charlotte Hemingway
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph M Lewis
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mandela Oguche
- LVCT Health, Sonning Suites, Suna Road off Ngong Rd, Adams Arcade, P.O. Box 19835, Nairobi, Kenya
| | - Vicki Doyle
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nelly Muturi
- Airbel Impact Lab- International Rescue Committee, Nairobi, Kenya
| | - Emily Ogwang
- LVCT Health, The Key Place, Along Homa Bay-Rongo Road, P.O Box 352-40300, Homabay, Kenya
| | | | - Miriam Taegtmeyer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
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Otiso L, Steege R, Njoroge I, Okoth L, Tubb P, Nyothach E, Phillips-Howard PA, Theobald S, Taegtmeyer M. Safeguarding in practice: anticipating, minimising and mitigating risk in teenage pregnancy research in urban informal settlements in Nairobi, Kenya. BMJ Glob Health 2024; 9:e013519. [PMID: 38423546 PMCID: PMC10910648 DOI: 10.1136/bmjgh-2023-013519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/10/2023] [Indexed: 03/02/2024] Open
Abstract
Safeguarding challenges in global health research include sexual abuse and exploitation, physical and psychological abuse, financial exploitation and neglect. Intersecting individual identities (such as gender and age) shape vulnerability to risk. Adolescents, who are widely included in sexual and reproductive health research, may be particularly vulnerable. Sensitive topics like teenage pregnancy may lead to multiple risks. We explored potential safeguarding risks and mitigation strategies when studying teenage pregnancies in informal urban settlements in Nairobi, Kenya. Risk mapping was initiated by the research team that had prolonged engagement with adolescent girls and teen mothers. The team mapped potential safeguarding risks for both research participants and research staff due to, and unrelated to, the research activity. Mitigation measures were agreed for each risk. The draft risk map was validated by community members and coresearchers in a workshop. During implementation, safeguarding risks emerged across the risk map areas and are presented as case studies. Risks to the girls included intimate partner violence because of a phone provided by the study; male participants faced potential disclosure of their perceived criminal activity (impregnating teenage girls); and researchers faced psychological and physical risks due to the nature of the research. These cases shed further light on safeguarding as a key priority area for research ethics and implementation. Our experience illustrates the importance of mapping safeguarding risks and strengthening safeguarding measures throughout the research lifecycle. We recommend co-developing and continuously updating a safeguarding map to enhance safety, equity and trust between the participants, community and researchers.
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Affiliation(s)
- Lilian Otiso
- LVCT Health, Nairobi, Kenya
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rosie Steege
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Phil Tubb
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Penelope A Phillips-Howard
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- CGHR, KEMRI, Kisumu, Kenya
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Karuga R, Kabaria C, Chumo I, Okoth L, Njoroge I, Otiso L, Muturi N, Karki J, Dean L, Tolhurst R, Steege R, Ozano K, Theobald S, Mberu B. Voices and challenges of marginalized and vulnerable groups in urban informal settlements in Nairobi, Kenya: building on a spectrum of community-based participatory research approaches. Front Public Health 2023; 11:1175326. [PMID: 38074741 PMCID: PMC10701261 DOI: 10.3389/fpubh.2023.1175326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
Urbanization is rapidly increasing across Africa, including in Nairobi, Kenya. Many people, recent migrants and long-term residents, live within dense and dynamic urban informal settlements. These contexts are fluid and heterogeneous, and deepening the understanding of how vulnerabilities and marginalization are experienced is important to inform pointed action, service delivery and policy priorities. The aim of this paper is to explore vulnerabilities and marginalization within Korogocho and Viwandani informal settlements in Nairobi and generate lessons on the value of a spectrum of community based participatory research approaches for understanding health and well-being needs and pinpointing appropriate interventions. In the exploratory stages of our ARISE consortium research, we worked with co-researchers to use the following methods: social mapping, governance diaries, and photo voice. Social mapping (including the use of Focus Group Discussions) identified key vulnerable groups: marginalized and precarious child heads of households (CHHs), Persons with disability who face multiple discrimination and health challenges, and often isolated older adults; and their priority needs, including health, education, water and sanitation. The governance diaries generated an understanding of the perceptions of the particularly vulnerable and marginalized informal settlement residents regarding the various people and institutions with the power to influence health and wellbeing; while photo voice highlighted the lived experiences of vulnerability and marginality. Understanding and responding to fluid and intersecting marginalities and vulnerabilities within growing urban informal settlements is particularly critical to achieving inclusive urbanization, where no one is left behind, a theme central to the Sustainable Development Goals and Kenya's Vision 2030.
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Affiliation(s)
- Robinson Karuga
- Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Caroline Kabaria
- Urbanization and Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Ivy Chumo
- Urbanization and Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Linet Okoth
- Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Inviolata Njoroge
- Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Lilian Otiso
- Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Nelly Muturi
- Airbel Impact Lab, International Rescue Committee, Nairobi, Kenya
| | - Jiban Karki
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Laura Dean
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rachel Tolhurst
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Rosie Steege
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kim Ozano
- The SCL Agency, Wales, United Kingdom
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Blessing Mberu
- Urbanization and Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
- Department of Demography and Population Studies, University of Witwatersrand, Johannesburg, South Africa
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Okoth L, Steege R, Ngunjiri A, Theobald S, Otiso L. Policy and practices shaping the delivery of health services to pregnant adolescents in informal urban settlements in Kenya. Health Policy Plan 2023; 38:ii25-ii35. [PMID: 37995266 PMCID: PMC10666924 DOI: 10.1093/heapol/czad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 11/25/2023] Open
Abstract
In Kenya, the pregnancy rate of 15% among adolescents aged 15-19 years is alarmingly high. Adolescent girls living in informal urban settlements are exposed to rapid socio-economic transitions and multiple intersecting health risks and may be particularly disadvantaged in accessing sexual reproductive health services. Understanding vulnerabilities and service-seeking behaviours from different perspectives is important in order to support the development and implementation of progressive policies and services that meet adolescents' unique needs within urban informal settlements. This study explored policy makers, community health service providers' and community members' perceptions of access to, and delivery of, sexual reproductive health services for pregnant adolescents in one informal urban settlement in Nairobi. We employed qualitative methods with respondents throughout the health system, purposively sampled by gender and diversity of roles. We conducted focus group discussions with community members (n = 2 female-only; n = 2 male-only), key informant interviews with policy makers (n = 8), traditional birth attendants (n = 12), community health volunteers (CHVs) (n = 11), a nutritionist (n = 1), social workers (n = 2) and clinical officers (n = 2). We analysed the data using thematic analysis. Government policies and strategies on sexual and reproductive health for adolescents exist in Kenya and there are examples of innovative and inclusive practice within facilities. Key factors that support the provision of services to pregnant adolescents include devolved governance, and effective collaboration and partnerships, including with CHVs. However, inadequate financing and medical supplies, human resource shortages and stigmatizing attitudes from health providers and communities, mean that pregnant adolescents from informal urban settlements often miss out on critical services. The provision of quality, youth-friendly reproductive health services for this group requires policies and practice that seek to achieve reproductive justice through centring the needs and realities of pregnant adolescents, acknowledging the complex and intersecting social inequities they face.
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Affiliation(s)
| | - Rosie Steege
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sally Theobald
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Ngũnjiri A, Memiah P, Kimathi R, Wagner FA, Ikahu A, Omanga E, Kweyu E, Ngunu C, Otiso L. Utilizing User Preferences in Designing the AGILE (Accelerating Access to Gender-Based Violence Information and Services Leveraging on Technology Enhanced) Chatbot. Int J Environ Res Public Health 2023; 20:7018. [PMID: 37947574 PMCID: PMC10647327 DOI: 10.3390/ijerph20217018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Technology advancements have enhanced artificial intelligence, leading to a user shift towards virtual assistants, but a human-centered approach is needed to assess for acceptability and effectiveness. The AGILE chatbot is designed in Kenya with features to redefine the response towards gender-based violence (GBV) among vulnerable populations, including adolescents, young women and men, and sexual and gender minorities, to offer accurate and reliable information among users. METHODS We conducted an exploratory qualitative study through focus group discussions (FGDs) targeting 150 participants sampled from vulnerable categories; adolescent girls and boys, young women, young men, and sexual and gender minorities. The FGDs included multiple inquiries to assess knowledge and prior interaction with intelligent conversational assistants to inform the user-centric development of a decision-supportive chatbot and a pilot of the chatbot prototype. Each focus group comprised 9-10 members, and the discussions lasted about two hours to gain qualitative user insights and experiences. We used thematic analysis and drew on grounded theory to analyze the data. RESULTS The analysis resulted in 14 salient themes composed of sexual violence, physical violence, emotional violence, intimate partner violence, female genital mutilation, sexual reproductive health, mental health, help-seeking behaviors/where to seek support, who to talk to, and what information they would like, features of the chatbot, access of chatbot, abuse and HIV, family and community conflicts, and information for self-care. CONCLUSION Adopting a human-centered approach in designing an effective chatbot with as many human features as possible is crucial in increasing utilization, addressing the gaps presented by marginalized/vulnerable populations, and reducing the current GBV epidemic by moving prevention and response services closer to people in need.
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Affiliation(s)
- Anne Ngũnjiri
- LVCT Health Kenya, Nairobi P.O. Box 19835-00202, Kenya; (A.N.); (R.K.); (A.I.); (E.O.); (L.O.)
| | - Peter Memiah
- Graduate School, University of Maryland, 620 W. Lexington Street, Baltimore, MD 21201, USA
| | - Robert Kimathi
- LVCT Health Kenya, Nairobi P.O. Box 19835-00202, Kenya; (A.N.); (R.K.); (A.I.); (E.O.); (L.O.)
| | - Fernando A. Wagner
- School of Social Work, University of Maryland, 525 W. Redwood Street, Baltimore, MD 21201, USA;
| | - Annrita Ikahu
- LVCT Health Kenya, Nairobi P.O. Box 19835-00202, Kenya; (A.N.); (R.K.); (A.I.); (E.O.); (L.O.)
| | - Eunice Omanga
- LVCT Health Kenya, Nairobi P.O. Box 19835-00202, Kenya; (A.N.); (R.K.); (A.I.); (E.O.); (L.O.)
| | - Emmanuel Kweyu
- Faculty of Information Technology, Strathmore University, Nairobi P.O. Box 59857-00200, Kenya;
| | - Carol Ngunu
- Department of Health, Nairobi City County, Nairobi P.O. Box 30075-00100, Kenya;
| | - Lilian Otiso
- LVCT Health Kenya, Nairobi P.O. Box 19835-00202, Kenya; (A.N.); (R.K.); (A.I.); (E.O.); (L.O.)
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Ringwald B, Taegtmeyer M, Mwania V, Muthoki M, Munyao F, Digolo L, Otiso L, Wangui Ngunjiri AS, Karuga RN, Tolhurst R. Power and poverty: A participatory study on the complexities of HIV and intimate partner violence in an informal urban settlement in Nairobi, Kenya. Soc Sci Med 2023; 336:116247. [PMID: 37797544 PMCID: PMC10622644 DOI: 10.1016/j.socscimed.2023.116247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 08/03/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal urban settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies.
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Affiliation(s)
- Beate Ringwald
- ARISE Hub, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK; Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Miriam Taegtmeyer
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | | | - Mary Muthoki
- LVCT Health, P.O. Box 19835-00202, KNH, Nairobi, Kenya
| | - Faith Munyao
- LVCT Health, P.O. Box 19835-00202, KNH, Nairobi, Kenya
| | - Lina Digolo
- The Prevention Collaborative, P.O. Box 3794 00100, Nairobi, Kenya
| | - Lilian Otiso
- LVCT Health, P.O. Box 19835-00202, KNH, Nairobi, Kenya
| | | | | | - Rachel Tolhurst
- ARISE Hub, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Ringwald B, Tolhurst R, Taegtmeyer M, Digolo L, Gichuna G, Gaitho MM, Phillips–Howard PA, Otiso L, Giorgi E. Intra-Urban Variation of Intimate Partner Violence Against Women and Men in Kenya: Evidence from the 2014 Kenya Demographic and Health Survey. J Interpers Violence 2023; 38:5111-5138. [PMID: 36062755 PMCID: PMC9900693 DOI: 10.1177/08862605221120893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although urban areas are diverse and urban inequities are well documented, surveys commonly differentiate intimate partner violence (IPV) rates only by urban versus rural residence. This study compared rates of current IPV victimization among women and men by urban residence (informal and formal settlements). Data from the 2014 Kenya Demographic and Health Survey, consisting of an ever-married sample of 1,613 women (age 15-49 years) and 1,321 men (age 15-54 years), were analyzed. Multilevel logistic regression was applied to female and male data separately to quantify the associations between residence and any current IPV while controlling for regional variation and other factors. Results show gendered patterns of intra-urban variation in IPV occurrence, with the greatest burden of IPV identified among women in informal settlements (across all types of violence). Unadjusted analyses suggest residing in informal settlements is associated with any current IPV against women, but not men, compared with their counterparts in formal urban settlements. This correlation is not statistically significant when adjusting for women's education level in multivariate analysis. In addition, reporting father beat mother, use of current physical violence against partner, partner's alcohol use, and marital status are associated with any current IPV against women and men. IPV gets marginal attention in urban violence and urban health research, and our results highlight the importance of spatially disaggregate IPV data-beyond the rural-urban divide-to inform policy and programming. Future research may utilize intersectional and syndemic approaches to investigate the complexity of IPV and clustering with other forms of violence and other health issues in different urban settings, especially among marginalized residents in informal urban settings.
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Affiliation(s)
| | | | | | - Lina Digolo
- The Prevention Collaborative, Nairobi,
Kenya
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Lapsley R, Beima-Sofie K, Moraa H, Manyeki V, Mung’ala C, Kohler PK, Simoni JM, Farquhar C, Inwani I, McClelland RS, Otiso L, Masyuko S, Bukusi D, Wilson KS. "They have given you the morale and confidence:" adolescents and young adults want more community-based oral HIV self-testing options in Kenya. AIDS Care 2023; 35:392-398. [PMID: 35468010 PMCID: PMC9592677 DOI: 10.1080/09540121.2022.2067315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
Community-based delivery of oral HIV self-testing (HIVST) may expand access to testing among adolescents and young adults (AYA). Eliciting youth perspectives can help to optimize these services. We conducted nine focus group discussions (FGDs) with HIV negative AYA aged 15-24 who had completed oral HIVST following community-based distribution through homes, pharmacies, and bars. FGDs were stratified by distribution point and age (15-17, 18-24). Participants valued HIVST because it promoted greater autonomy and convenience compared to traditional clinic-based testing. AYA noted how HIVST could encourage positive behavior change, including using condoms to remain HIV negative. Participants recommended that future testing strategies include individualized, ongoing support during and after testing. Support examples included access to trained peer educators, multiple community-based distribution points, and post-test support via phones and websites. Multiple distribution points and trained peer educators' involvement in all steps of distribution, testing, and follow-up can enhance future community-based HIVST programs.
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Affiliation(s)
- Robert Lapsley
- Department of Global Health, University of Washington, Seattle, USA
| | | | - Hellen Moraa
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mung’ala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
| | - Jane M. Simoni
- Department of Global Health, University of Washington, Seattle, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | | | - R. Scott McClelland
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | | | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | | | - Kate S. Wilson
- Department of Global Health, University of Washington, Seattle, USA
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Karuga R, Kok M, Mbindyo P, Otiso L, Macharia J, Broerse JEW, Dieleman M. How context influences the functionality of community-level health governance structures: A case study of community health committees in Kenya. Int J Health Plann Manage 2023; 38:702-722. [PMID: 36781772 DOI: 10.1002/hpm.3619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/06/2022] [Accepted: 01/30/2023] [Indexed: 02/15/2023] Open
Abstract
Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community-level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya. Using a case study design, we explored the influence of context on CHCs using 18 focus group discussions with 110 community members (clients, CHC members, and community health volunteers [CHVs]) and interviews with 33 health professionals. Essential CHC functions such as 'leadership' and 'management' were weak, partly because Health professionals did not involve CHCs in developing health plans. Community Health Committees were active in the supervision of CHVs, reviewing their household reports, although they did not utilise these data for making decisions. Resource mobilisation and evaluation of health programs were affected by the lack of administrative and operational support, such as training. Despite having influential membership, CHCs could not provide leadership and management functions. Health system actors perceived the roles of CHCs as service providers rather than structures for governance and oversight. Insufficient awareness of CHC roles among health professionals, lack of training and operational support for community-based activities constrained CHCs' functionality and thus their role in community participation. While there are efforts to institutionalise community-level governance structures for health at sub-national level, there is a need to scale-up these efforts countrywide. We recommend that community-level governance structures be empowered, mandated, and provided with resources to take on the responsibility of overseeing community health services and exacting accountability from health providers.
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Affiliation(s)
- Robinson Karuga
- LVCT Health, Nairobi, Kenya.,Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maryse Kok
- KIT Royal Tropical Institute (Koninklijk Instituut voor de Tropen), Amsterdam, The Netherlands
| | - Patrick Mbindyo
- Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | | | - Judy Macharia
- Directorate of Preventive and Promotive Health, Nairobi, Kenya
| | - Jacqueline E W Broerse
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Marjolein Dieleman
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands.,KIT Royal Tropical Institute (Koninklijk Instituut voor de Tropen), Amsterdam, The Netherlands
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Gachigua SG, Karuga R, Ngunjiri A, Jarrahian C, Coffey PS, Kilbourne-Brook M, Otiso L. Microarray patch for HIV prevention and as a multipurpose prevention technology to prevent HIV and unplanned pregnancy: an assessment of potential acceptability, usability, and programmatic fit in Kenya. Front Reprod Health 2023; 5:1125159. [PMID: 37168102 PMCID: PMC10164997 DOI: 10.3389/frph.2023.1125159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/04/2023] [Indexed: 05/13/2023] Open
Abstract
Background Microarray patches (MAPs), a novel drug delivery system, are being developed for HIV pre-exposure prophylaxis (PrEP) delivery and as a multipurpose prevention technology (MPT) to protect from both HIV and unintended pregnancy. Prevention technologies must meet the needs of target audiences, be acceptable, easy to use, and fit health system requirements. Methodology We explored perceptions about MAP technology and assessed usability, hypothetical acceptability, and potential programmatic fit of MAP prototypes using focus group discussions (FGD), usability exercises, and key informant interviews (KII) among key populations in Kiambu County, Kenya. Adolescent girls and young women (AGYW), female sex workers (FSW), and men who have sex with men (MSM) assessed the usability and acceptability of a MAP prototype. Male partners of AGYW/FSW assessed MAP acceptability as partners of likely users. We analyzed data using NVivo, applying an inductive approach. Health service providers and policymakers assessed programmatic fit. Usability exercise participants applied a no-drug, no-microneedle MAP prototype and assessed MAP features. Results We implemented 10 FGD (4 AGYW; 2 FSW; 2 MSM; 2 male partners); 47 mock use exercises (19 AGYW; 9 FSW; 8 MSM; 11 HSP); and 6 policymaker KII. Participants reported high interest in MAPs due to discreet and easy use, long-term protection, and potential for self-administration. MAP size and duration of protection were key characteristics influencing acceptability. Most AGYW preferred the MPT MAP over an HIV PrEP-only MAP. FSW saw value in both MAP indications and voiced need for MPTs that protect from other infections. Preferred duration of protection was 1-3 months. Some participants would accept a larger MAP if it provided longer protection. Participants suggested revisions to the feedback indicator to improve confidence. Policymakers described the MPT MAP as "killing two birds with one stone," in addressing AGYW needs for both HIV protection and contraception. An MPT MAP is aligned with Kenya's policy of integrating health care programs. Conclusions MAPs for HIV PrEP and as an MPT both were acceptable across participant groups. Some groups valued an MPT MAP over an HIV PrEP MAP. Prototype refinements will improve usability and confidence.
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Affiliation(s)
| | | | | | - Courtney Jarrahian
- Medical Devices and Health Technologies, PATH, Seattle, WA, United States
| | - Patricia S. Coffey
- Medical Devices and Health Technologies, PATH, Seattle, WA, United States
| | - Maggie Kilbourne-Brook
- Medical Devices and Health Technologies, PATH, Seattle, WA, United States
- Correspondence: Maggie Kilbourne-Brook
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Driver M, Katz DA, Manyeki V, Mungala C, Otiso L, Mugo C, McClelland S, Kohler P, Simoni JM, Inwani I, Wilson K. Condom Use Behaviors, Risk Perception, and Partner Communication Following Oral HIV Self-testing Among Adolescents and Young Adults in Kenya: A Cohort Study. AIDS Behav 2022; 27:1727-1740. [PMID: 36520337 DOI: 10.1007/s10461-022-03904-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 12/23/2022]
Abstract
HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15-24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships.
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Affiliation(s)
- Matthew Driver
- Department of Epidemiology, University of Washington, Seattle, USA
| | - David A Katz
- Department of Global Health, University of Washington, Seattle, USA
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Caroline Mungala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | | | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, USA
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, University of Washington, Seattle, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Irene Inwani
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Kate Wilson
- Department of Global Health, University of Washington, Seattle, USA.
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12
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Adams C, Kiruki M, Karuga R, Otiso L, Graham SM, Beima-Sofie KM. "Your status cannot hinder you": the importance of resilience among adolescents engaged in HIV care in Kenya. BMC Public Health 2022; 22:1272. [PMID: 35773690 PMCID: PMC9245269 DOI: 10.1186/s12889-022-13677-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Approximately 40% of the 110,000 adolescents living with HIV (ALHIV) in Kenya have not achieved viral suppression. Despite the increasing availability of adolescent-friendly services, adolescents face barriers that impact ART adherence. This study aimed to identify key stigma-related barriers to ART adherence and strategies used by adolescents in overcoming these barriers. METHODS Data were collected by LVCT Health, a Kenyan organization with a programmatic focus on HIV testing, prevention, and care. 122 participants were recruited from 3 clinical sites affiliated with LVCT Health in Nairobi, Kisumu, and Mombasa. In-depth interviews were conducted with ALHIV (n = 12). Focus group discussions were conducted with ALHIV (n = 5), peer leaders (n = 3), and adolescents receiving HIV services in community settings (AIC) irrespective of HIV status (n = 3). Interviews and focus groups were audio recorded, translated, and transcribed. Data were analyzed thematically, with a focus on stigma and resilience. RESULTS While AIC primarily focused on adherence barriers and stigma, ALHIV and, to some extent, peer leaders, also identified resilience factors that helped overcome stigma. Four major themes emerged: 1) knowledge and future-oriented goals can drive motivation for ALHIV to remain healthy; 2) disclosure to others strengthens support systems for ALHIV; 3) medication-taking strategies and strategic disclosure can overcome adherence challenges in school; and 4) a supportive clinic environment promotes continuous adolescent engagement in HIV care. These concepts were used to develop a conceptual stigma/resilience model depicting how resilience moderates negative effects of stigma among ALHIV. CONCLUSIONS This study demonstrates the positive effects of ALHIV resilience on ART adherence and illuminates how stigma impacts ALHIV differently depending on their resilience. Strengths-based interventions, focused on increasing resilience among ALHIV in Kenya, and more formal involvement of adolescent peers to bolster adolescent support, have the potential to improve ART adherence among ALHIV.
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Affiliation(s)
- Casey Adams
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Social Work, University of Washington, Seattle, WA USA
| | - Millicent Kiruki
- grid.463443.20000 0004 0372 7280Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Robinson Karuga
- grid.463443.20000 0004 0372 7280Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Lilian Otiso
- grid.463443.20000 0004 0372 7280Department of Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Susan M. Graham
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Medicine, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Department of Epidemiology, University of Washington, Seattle, WA USA
| | - Kristin M. Beima-Sofie
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
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Wilson KS, Mugo C, Katz DA, Manyeki V, Mungwala C, Otiso L, Bukusi D, McClelland RS, Simoni JM, Driver M, Masyuko S, Inwani I, Kohler PK. High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy. AIDS Behav 2022; 26:964-974. [PMID: 34468968 PMCID: PMC8409270 DOI: 10.1007/s10461-021-03451-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/01/2023]
Abstract
Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15-24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA.
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Affiliation(s)
- Kate S Wilson
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA.
| | - Cyrus Mugo
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - David A Katz
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mungwala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - R Scott McClelland
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Matt Driver
- Department of Cardiology, Cedar Sinai Medical Center, Los Angeles, USA
| | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | - Irene Inwani
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K Kohler
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
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Aktar B, Alam W, Ali S, Awal A, Bayoh M, Chumo I, Contay Y, Conteh A, Dean L, Dobson S, Edstrom J, Elsey H, Farnaz N, Garimella S, Gray L, Gupte J, Hawkins K, Hollihead B, Josyula KL, Kabaria C, Karuga R, Kimani J, Leyland AH, Te Lintelo D, Mansaray B, MacCarthy J, MacGregor H, Mberu B, Muturi N, Okoth L, Otiso L, Ozano K, Parray A, Phillips-Howard P, Rao V, Rashid S, Raven J, Refell F, Saidu S, Sobhan S, Saligram PS, Sesay S, Theobald S, Tolhurst R, Tubb P, Waldman L, Wariutu J, Whittaker L, Wurie H. How to prevent and address safeguarding concerns in global health research programmes: practice, process and positionality in marginalised spaces. BMJ Glob Health 2021; 5:bmjgh-2019-002253. [PMID: 32409330 PMCID: PMC7228499 DOI: 10.1136/bmjgh-2019-002253] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/12/2022] Open
Abstract
Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.
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Affiliation(s)
- Bachera Aktar
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Wafa Alam
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Samiha Ali
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Abdul Awal
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Margaret Bayoh
- Federation of Urban and Rural Poor, Freetown, Sierra Leone
| | - Ivy Chumo
- African Population and Health Research Center, Nairobi, Kenya
| | - Yirah Contay
- Federation of Urban and Rural Poor, Freetown, Sierra Leone
| | - Abu Conteh
- Sierra Leone Urban Research Centre, Njala University, Freetown, Sierra Leone
| | - Laura Dean
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Skye Dobson
- Slum Dwellers International, Cape Town, South Africa
| | - Jerker Edstrom
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Helen Elsey
- Health Sciences, University of York, York, UK
| | - Nadia Farnaz
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | | | - Jaideep Gupte
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Kate Hawkins
- Pamoja Communications, Brighton and Hove, United Kingdom
| | - Beth Hollihead
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | | | | | | | - Joseph Kimani
- Slum and Shack Dwellers International Kenya, Nairobi, Kenya
| | | | - Dolf Te Lintelo
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Bintu Mansaray
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Joseph MacCarthy
- Sierra Leone Urban Research Centre, Njala University, Freetown, Sierra Leone
| | - Hayley MacGregor
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Blessing Mberu
- African Population and Health Research Center, Nairobi, Kenya
| | | | | | | | - Kim Ozano
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Ateeb Parray
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | | | - Sabina Rashid
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | | | - Samuel Saidu
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Shafinaz Sobhan
- BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
| | | | - Samira Sesay
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Sally Theobald
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Rachel Tolhurst
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Phil Tubb
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Linda Waldman
- Institute of Development Studies, Brighton, Brighton and Hove, UK
| | - Jane Wariutu
- Slum and Shack Dwellers International Kenya, Nairobi, Kenya
| | - Lana Whittaker
- Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
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Chen N, Raghavan M, Albert J, McDaniel A, Otiso L, Kintu R, West M, Jacobstein D. The Community Health Systems Reform Cycle: Strengthening the Integration of Community Health Worker Programs Through an Institutional Reform Perspective. Glob Health Sci Pract 2021; 9:S32-S46. [PMID: 33727319 PMCID: PMC7971380 DOI: 10.9745/ghsp-d-20-00429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/07/2021] [Indexed: 11/15/2022]
Abstract
To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.
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Affiliation(s)
- Nan Chen
- Last Mile Health, Washington, DC, USA.
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Hussein S, Otiso L, Kimani M, Olago A, Wanyungu J, Kavoo D, Njiraini R, Kimanzi S, Karuga R. Institutionalizing Community Health Services in Kenya: A Policy and Practice Journey. Glob Health Sci Pract 2021; 9:S25-S31. [PMID: 33727318 PMCID: PMC7971377 DOI: 10.9745/ghsp-d-20-00430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/07/2021] [Indexed: 11/16/2022]
Abstract
The process of institutionalizing community health services in Kenya required strong leadership by the Ministry of Health, effective coordination and support of stakeholders, and alignment of community health with the political priorities at the national and decentralized government levels to facilitate adequate prioritization and financing of the community health strategy.
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Affiliation(s)
| | | | | | | | | | | | - Rose Njiraini
- Kenya Country Office, United Nations Children's Fund, Nairobi, Kenya
| | - Sila Kimanzi
- U.S. Agency for International Development, Nairobi, Kenya
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Kumar MB, Madan JJ, Auguste P, Taegtmeyer M, Otiso L, Ochieng CB, Muturi N, Mgamb E, Barasa E. Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya. BMJ Glob Health 2021; 6:e002452. [PMID: 33658302 PMCID: PMC7931757 DOI: 10.1136/bmjgh-2020-002452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya. METHODS We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses. RESULTS We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars). CONCLUSIONS This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.
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Affiliation(s)
- Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jason J Madan
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Peter Auguste
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | | | - Nelly Muturi
- Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Elizabeth Mgamb
- Department of Health, Migori County Government, Migori, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
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Regeru RN, Chikaphupha K, Bruce Kumar M, Otiso L, Taegtmeyer M. 'Do you trust those data?'-a mixed-methods study assessing the quality of data reported by community health workers in Kenya and Malawi. Health Policy Plan 2020; 35:334-345. [PMID: 31977014 PMCID: PMC7152729 DOI: 10.1093/heapol/czz163] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 11/13/2022] Open
Abstract
High-quality data are essential to monitor and evaluate community health worker (CHW) programmes in low- and middle-income countries striving towards universal health coverage. This mixed-methods study was conducted in two purposively selected districts in Kenya (where volunteers collect data) and two in Malawi (where health surveillance assistants are a paid cadre). We calculated data verification ratios to quantify reporting consistency for selected health indicators over 3 months across 339 registers and 72 summary reports. These indicators are related to antenatal care, skilled delivery, immunization, growth monitoring and nutrition in Kenya; new cases, danger signs, drug stock-outs and under-five mortality in Malawi. We used qualitative methods to explore perceptions of data quality with 52 CHWs in Kenya, 83 CHWs in Malawi and 36 key informants. We analysed these data using a framework approach assisted by NVivo11. We found that only 15% of data were reported consistently between CHWs and their supervisors in both contexts. We found remarkable similarities in our qualitative data in Kenya and Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. In addition, we found that CHWs experienced tensions at the interface between the formal health system and the communities they served, mediated by the social and cultural expectations of their role. These issues affected data quality in both contexts with reports of difficulties in negotiating gender norms leading to skipping sensitive questions when completing registers; fabrication of data; lack of trust in the data; and limited use of data for decision-making. While routine systems need strengthening, these more nuanced issues also need addressing. This is backed up by our finding of the high value placed on supportive supervision as an enabler of data quality.
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Affiliation(s)
| | | | - Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Lilian Otiso
- Research Division, LVCT Health, PO Box 19835-00202, Nairobi, Kenya
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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19
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Agarwal S, Sripad P, Johnson C, Kirk K, Bellows B, Ana J, Blaser V, Kumar MB, Buchholz K, Casseus A, Chen N, Dini HSF, Deussom RH, Jacobstein D, Kintu R, Kureshy N, Meoli L, Otiso L, Pakenham-Walsh N, Zambruni JP, Raghavan M, Schwarz R, Townsend J, Varpilah B, Weiss W, Warren CE. A conceptual framework for measuring community health workforce performance within primary health care systems. Hum Resour Health 2019; 17:86. [PMID: 31747947 PMCID: PMC6868857 DOI: 10.1186/s12960-019-0422-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/24/2019] [Indexed: 05/23/2023]
Abstract
BACKGROUND With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. METHODS A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. RESULTS Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. CONCLUSIONS Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.
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Affiliation(s)
- Smisha Agarwal
- Population Council, Washington, DC USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | | | | | | | - Joseph Ana
- Healthcare Information For All (HIFA), Oxford, UK
| | | | - Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | | | | | | | | | | | | | - Lilian Otiso
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA USA
| | | | | | - William Weiss
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
- USAID, Washington, DC USA
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Karuga RN, Kok M, Mbindyo P, Hilverda F, Otiso L, Kavoo D, Broerse J, Dieleman M. "It's like these CHCs don't exist, are they featured anywhere?": Social network analysis of community health committees in a rural and urban setting in Kenya. PLoS One 2019; 14:e0220836. [PMID: 31393923 PMCID: PMC6687128 DOI: 10.1371/journal.pone.0220836] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/25/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In Kenya, Community Health Committees (CHC) were established to enhance community participation in health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. CHCs form social networks with other actors, with whom they exchange health information for decision-making and accountability. This case study aimed to explore the structure of a rural and an urban CHC network and to analyze how health-related information flowed in these networks. Understanding the pathways of information in community settings may provide recommendations for strategies to improve the role and functioning of CHCs. METHODS In 2017, we conducted 4 focus group discussions with 27 community discussants and 10 semi-structured interviews with health professionals in a rural area and an urban slum. Using social network analysis, we determined the structure of their social networks and how health related information flowed in these networks. RESULTS Both CHCs were composed of respected persons nominated by their communities. Each social network had 12 actors that represented both community and government institutions. CHCs were not central actors in the exchange of health-related information. Health workers, community health volunteers and local Chiefs in the urban slum often passed information between the different groups of actors, while CHCs hardly did this. Therefore, CHCs had little control over the flow of health-related information. Although CHC members were respected persons who served in multiple roles within their communities, this did not enhance their centrality. It emerged that CHCs were often left out in the flow of health-related information and decision-making, which led to demotivation. Community health volunteers were more involved by other actors such as health managers and non-governmental organizations as a conduit for health-related information. CONCLUSION Social network analysis demonstrated how CHCs played a peripheral role in the flow of health-related information. Their perception of being left out of the information flow led to demotivation, which hampered their ability to facilitate community participation in community health services; hence challenging effective participation through CHCs.
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Affiliation(s)
- Robinson Njoroge Karuga
- LVCT Health, Nairobi, Kenya.,Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maryse Kok
- Royal Tropical Institute (KIT), Amsterdam, The Netherlands
| | - Patrick Mbindyo
- Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Femke Hilverda
- School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | | | - Daniel Kavoo
- Community Health and Development Unit, Ministry of Health, Nairobi, Kenya
| | - Jaqueline Broerse
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Marjolein Dieleman
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands.,Royal Tropical Institute (KIT), Amsterdam, The Netherlands
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Ormel H, Kok M, Kane S, Ahmed R, Chikaphupha K, Rashid SF, Gemechu D, Otiso L, Sidat M, Theobald S, Taegtmeyer M, de Koning K. Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation. Hum Resour Health 2019; 17:59. [PMID: 31324192 PMCID: PMC6642499 DOI: 10.1186/s12960-019-0387-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/20/2019] [Indexed: 05/28/2023]
Abstract
BACKGROUND The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. METHODS We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. RESULTS We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. CONCLUSIONS Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.
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Affiliation(s)
- Hermen Ormel
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Maryse Kok
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Sumit Kane
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Rukhsana Ahmed
- Eijkman Institute for Molecular Biology, Jalan Diponegoro 69, Jakarta, 10430 Indonesia
| | - Kingsley Chikaphupha
- Research for Equity and Community Health (REACH) Trust, P.O. Box 1597, Lilongwe, Malawi
| | - Sabina Faiz Rashid
- BRAC James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka Bangladesh
| | | | - Lilian Otiso
- LVCT Health, Research and Strategic Information Department, P.O. Box 19835-00202, Nairobi, Kenya
| | - Mohsin Sidat
- Department of Community Health, University Eduardo Mondlane, P.O. Box 257, Maputo, Mozambique
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Korrie de Koning
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
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Karuga RN, Mireku M, Muturi N, McCollum R, Vallieres F, Kumar M, Taegtmeyer M, Otiso L. Supportive supervision of close-to-community providers of health care: Findings from action research conducted in two counties in Kenya. PLoS One 2019; 14:e0216444. [PMID: 31141509 PMCID: PMC6541245 DOI: 10.1371/journal.pone.0216444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/22/2019] [Indexed: 11/19/2022] Open
Abstract
Background Close-to-community (CTC) providers of health care are a crucial workforce for delivery of high-quality and universal health coverage. There is limited evidence on the effect of training supervisors of this cadre in supportive supervision. Our study aimed to demonstrate the effects of a training intervention on the approach to and frequency of supervision of CTC providers of health care. Methods We conducted a context analysis in 2013 in two Kenyan counties to assess factors that influenced delivery of community health services. Supervision was identified a priority factor that needed to be addressed to improve community health services. Supervision was inadequate due to lack of supervisor capacity in supportive approaches and lack of supervision guidelines. We designed a six-day training intervention and trained 48 purposively selected CTC supervisors on the educative, administrative and supportive components of supportive supervision, problem solving and advocacy and provided them with checklists to guide supervision sessions. We administered quantitative questionnaires to supervisors to assess changes in supervision frequency before and after the training and then explored perspectives on the intervention with community health volunteers (CHVs) and their supervisors using qualitative in-depth interviews. Results Six months after the intervention, we observed that supervisors had shifted the supervision approach from being controlling and administrative to coaching, mentorship and problem solving. Changes in the frequency of supervision were found in Kitui only, whereby significant decreases in group supervision were met with increases in accompanied home visit supervision. Supervisors and CHVs reported the intervention was helpful and it responded to capacity gaps in supervision of CHVs. Conclusion Our intervention responded to capacity gaps in supervision and contributed to enhanced supervision capacity among supervisors. Supervisors found the curriculum acceptable and useful in improving supervision skills.
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Affiliation(s)
| | - Maryline Mireku
- LVCT Health, Department of Research and Strategic Information, Nairobi, Kenya
| | - Nelly Muturi
- LVCT Health, Department of Research and Strategic Information, Nairobi, Kenya
| | - Rosalind McCollum
- Liverpool School of Tropical Medicine, Department of International Public Health, Liverpool, United Kingdom
| | - Frederique Vallieres
- Centre for Global Health, School of Psychology, Trinity College, Dublin, Ireland
| | - Meghan Kumar
- Liverpool School of Tropical Medicine, Department of International Public Health, Liverpool, United Kingdom
| | - Miriam Taegtmeyer
- Liverpool School of Tropical Medicine, Department of International Public Health, Liverpool, United Kingdom
| | - Lilian Otiso
- LVCT Health, Department of Research and Strategic Information, Nairobi, Kenya
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McCollum R, Taegtmeyer M, Otiso L, Mireku M, Muturi N, Martineau T, Theobald S. Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya. Int J Equity Health 2019; 18:65. [PMID: 31064355 PMCID: PMC6505258 DOI: 10.1186/s12939-019-0967-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/22/2019] [Indexed: 01/17/2023] Open
Abstract
Background Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi’s equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. Methods We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Results Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. Conclusions If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | | | | | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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McCollum R, Taegtmeyer M, Otiso L, Tolhurst R, Mireku M, Martineau T, Karuga R, Theobald S. Applying an intersectionality lens to examine health for vulnerable individuals following devolution in Kenya. Int J Equity Health 2019; 18:24. [PMID: 30700299 PMCID: PMC6352384 DOI: 10.1186/s12939-019-0917-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Power imbalances are a key driver of avoidable, unfair and unjust differences in health. Devolution shifts the balance of power in health systems. Intersectionality approaches can provide a 'lens' for analysing how power relations contribute to complex and multiple forms of health advantage and disadvantage. These approaches have not to date been widely used to analyse health systems reforms. While the stated objectives of devolution often include improved equity, efficiency and community participation, past evidence demonstrates that that there is a need to create space and capacity for people to transform existing power relations these within specific contexts. METHODS We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from across the health system in ten counties, 14 focus group discussions with community members in two of these counties and photovoice participatory research with nine young people. We adopted an intersectionality lens to reveal how power relations intersect to produce vulnerabilities for specific groups in specific contexts, and to identify examples of the tacit knowledge about these vulnerabilities held by priority-setting stakeholders, in the wake of the introduction of devolution reforms in Kenya. RESULTS Our study identified a range of ways in which longstanding social forces and discriminations limit the power and agency individuals can exercise, but are mediated by their unique circumstances at a given point in their life. These are the social determinants of health, influencing an individual's exposure to risk of ill health from their living environment, their work, or their social context, including social norms relating to their gender, age, geographical residence or socio-economic status. While a range of policy measures have been introduced to encourage participation by typically 'unheard voices', devolution processes have yet to adequately challenge the social norms, and intersecting power relations which contribute to discrimination and marginalisation. CONCLUSIONS If key actors in devolved decision-making structures are to ensure progress towards universal health coverage, there is need for intersectoral policy action to address social determinants, promote equity and identify ways to challenge and shift power imbalances in priority-setting processes.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Rachel Tolhurst
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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McCollum R, Taegtmeyer M, Otiso L, Muturi N, Barasa E, Molyneux S, Martineau T, Theobald S. "Sometimes it is difficult for us to stand up and change this": an analysis of power within priority-setting for health following devolution in Kenya. BMC Health Serv Res 2018; 18:906. [PMID: 30486867 PMCID: PMC6264027 DOI: 10.1186/s12913-018-3706-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/12/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Practices of power lie at the heart of policy processes. In both devolution and priority-setting, actors seek to exert power through influence and control over material, human, intellectual and financial resources. Priority-setting arises as a consequence of the needs and demand exceeding the resources available, requiring some means of choosing between competing demands. This paper examines the use of power within priority-setting processes for healthcare resources at sub-national level, following devolution in Kenya. METHODS We interviewed 14 national level key informants and 255 purposively selected respondents from across the health system in ten counties. These qualitative data were supplemented by 14 focus group discussions (FGD) involving 146 community members in two counties. We conducted a power analysis using Gaventa's power cube and Veneklasen's expressions of power to interpret our findings. RESULTS We found Kenya's transition towards devolution is transforming the former centralised balance of power, leading to greater ability for influence at the county level, reduced power at national and sub-county (district) levels, and limited change at community level. Within these changing power structures, politicians are felt to play a greater role in priority-setting for health. The interfaces and tensions between politicians, health service providers and the community has at times been felt to undermine health related technical priorities. Underlying social structures and discriminatory practices generally continue unchanged, leading to the continued exclusion of the most vulnerable from priority-setting processes. CONCLUSIONS Power analysis of priority-setting at county level after devolution in Kenya highlights the need for stronger institutional structures, processes and norms to reduce the power imbalances between decision-making actors and to enable community participation.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- KEMRI Centre for Geographic Medicine Research - Coast, and Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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26
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McCollum R, Theobald S, Otiso L, Martineau T, Karuga R, Barasa E, Molyneux S, Taegtmeyer M. Priority setting for health in the context of devolution in Kenya: implications for health equity and community-based primary care. Health Policy Plan 2018; 33:729-742. [PMID: 29846599 PMCID: PMC6005116 DOI: 10.1093/heapol/czy043] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2018] [Indexed: 11/14/2022] Open
Abstract
Devolution changes the locus of power within a country from central to sub-national levels. In 2013, Kenya devolved health and other services from central government to 47 new sub-national governments (known as counties). This transition seeks to strengthen democracy and accountability, increase community participation, improve efficiency and reduce inequities. With changing responsibilities and power following devolution reforms, comes the need for priority-setting at the new county level. Priority-setting arises as a consequence of the needs and demand for healthcare resources exceeding the resources available, resulting in the need for some means of choosing between competing demands. We sought to explore the impact of devolution on priority-setting for health equity and community health services. We conducted key informant and in-depth interviews with health policymakers, health providers and politicians from 10 counties (n = 269 individuals) and 14 focus group discussions with community members based in 2 counties (n = 146 individuals). Qualitative data were analysed using the framework approach. We found Kenya’s devolution reforms were driven by the need to demonstrate responsiveness to county contexts, with positive ramifications for health equity in previously neglected counties. The rapidity of the process, however, combined with limited technical capacity and guidance has meant that decision-making and prioritization have been captured and distorted for political and power interests. Less visible community health services that focus on health promotion, disease prevention and referral have been neglected within the prioritization process in favour of more tangible curative health services. The rapid transition in power carries a degree of risk of not meeting stated objectives. As Kenya moves forward, decision-makers need to address the community health gap and lay down institutional structures, processes and norms which promote health equity for all Kenyans.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Sassy Molyneux
- KEMRI Centre for Geographic Medicine Research-Coast, and Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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McCollum R, Limato R, Otiso L, Theobald S, Taegtmeyer M. Health system governance following devolution: comparing experiences of decentralisation in Kenya and Indonesia. BMJ Glob Health 2018; 3:e000939. [PMID: 30294460 PMCID: PMC6169670 DOI: 10.1136/bmjgh-2018-000939] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Devolution reforms in Indonesia and Kenya have brought extensive changes to governance structures and mechanisms for financing and delivering healthcare. Community health approaches can contribute towards attaining many of devolution's objectives, including community participation, responsiveness, accountability and improved equity. We set out to examine governance in two countries at different stages in the devolution journey: Indonesia at 15 years postdevolution and Kenya at 3 years. METHODS We collected qualitative data across multiple levels of the health system in one district in Indonesia and ten counties in Kenya, through 80 interviews and six focus group discussions (FGD) in Indonesia and 269 interviews and 14 FGDs in Kenya. Qualitative data were digitally recorded, transcribed and coded before thematic framework analysis. Common themes between contexts were identified inductively and deductively, and similarities and differences critically analysed during an inter-country analysis workshop. RESULTS Following devolution both Indonesia and Kenya experienced similar challenges ensuring good governance for health. Devolution reforms transformed power relationships, increasing responsibilities at subnational levels and introducing opportunities for citizen participation. In both contexts, the impact of these mechanisms has been undermined by insufficiently clear guidance; failure to address pre-existing negative contextual norms and practices varied decision-maker values, limited priority-setting capacity and limited genuine community accountability. As a consequence, priorities in both contexts are too often placed on curative rather than preventive health services. CONCLUSION We recommend consideration of increased intersectoral actions that address social determinants of health, challenge negative norms and practices and place emphasis on community-based primary health services.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Steege R, Taegtmeyer M, McCollum R, Hawkins K, Ormel H, Kok M, Rashid S, Otiso L, Sidat M, Chikaphupha K, Datiko DG, Ahmed R, Tolhurst R, Gomez W, Theobald S. How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework. Soc Sci Med 2018; 209:1-13. [PMID: 29777956 DOI: 10.1016/j.socscimed.2018.05.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 11/18/2022]
Abstract
Close-to-community (CTC) providers have been identified as a key cadre to progress universal health coverage and address inequities in health service provision due to their embedded position within communities. CTC providers both work within, and are subject to, the gender norms at community level but may also have the potential to alter them. This paper synthesises current evidence on gender and CTC providers and the services they deliver. This study uses a two-stage exploratory approach drawing upon qualitative research from the six countries (Bangladesh, Indonesia, Ethiopia, Kenya, Malawi, Mozambique) that were part of the REACHOUT consortium. This research took place from 2013 to 2014. This was followed by systematic review that took place from January-September 2017, using critical interpretive synthesis methodology. This review included 58 papers from the literature. The resulting findings from both stages informed the development of a conceptual framework. We present the holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, influence of family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. We present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities. Gender roles and relations shape CTC provider experiences across multiple levels of the health system. To strengthen the equity and efficiency of CTC programmes gender dynamics should be considered by policymakers and implementers during both the conceptualisation and implementation of CTC programmes.
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Affiliation(s)
- Rosalind Steege
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK
| | - Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK
| | - Kate Hawkins
- Pamoja Communications, UK Bishopstone, 36 Crescent Road, Worthing BN11 1RL, UK
| | - Hermen Ormel
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands
| | - Maryse Kok
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands
| | - Sabina Rashid
- James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Lilian Otiso
- LVCT Health, Research and Strategic Information Department, P.O Box 19835- 00202, Nairobi, Kenya
| | - Mohsin Sidat
- University Eduardo Mondlane, Department of Community Health, P.O. Box 257, Maputo, Mozambique
| | - Kingsley Chikaphupha
- Research for Equity and Community Health (REACH) Trust, P.O. Box 1597, Lilongwe, Malawi
| | | | - Rukhsana Ahmed
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK; Eijkman Institute for Molecular Biology, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia, Jalan Diponegoro 69, Jakarta, 10430, Indonesia
| | - Rachel Tolhurst
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK
| | - Woedem Gomez
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, UK
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Otiso L, McCollum R, Mireku M, Karuga R, de Koning K, Taegtmeyer M. Decentralising and integrating HIV services in community-based health systems: a qualitative study of perceptions at macro, meso and micro levels of the health system. BMJ Glob Health 2017; 2:e000107. [PMID: 28588995 PMCID: PMC5321381 DOI: 10.1136/bmjgh-2016-000107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 11/17/2016] [Accepted: 11/22/2016] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION HIV services at the community level in Kenya are currently delivered largely through vertical programmes. The funding for these programmes is declining at the same time as the tasks of delivering HIV services are being shifted to the community. While integrating HIV into existing community health services creates a platform for increasing coverage, normalising HIV and making services more sustainable in high-prevalence settings, little is known about the feasibility of moving to a more integrated approach or about how acceptable such a move would be to the affected parties. METHODS We used qualitative methods to explore perceptions of integrating HIV services in two counties in Kenya, interviewing national and county policymakers, county-level implementers and community-level actors. Data were recorded digitally, translated, transcribed and coded in NVivo10 prior to a framework analysis. RESULTS We found that a range of HIV-related roles such as counselling, testing, linkage, adherence support and home-based care were already being performed in the community in an ad hoc manner. However, respondents expressed a desire for a more coordinated approach and for decentralising the integration of HIV services to the community level as parallel programming had resulted in gaps in HIV service and planning. In particular, integrating home-based testing and counselling within government community health structures was considered timely. CONCLUSIONS Integration can normalise HIV testing in Kenyan communities, integrate lay counsellors into the health system and address community desires for a household-led approach.
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Affiliation(s)
| | - Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Kane S, Kok M, Ormel H, Otiso L, Sidat M, Namakhoma I, Nasir S, Gemechu D, Rashid S, Taegtmeyer M, Theobald S, de Koning K. Limits and opportunities to community health worker empowerment: A multi-country comparative study. Soc Sci Med 2016; 164:27-34. [PMID: 27459022 DOI: 10.1016/j.socscimed.2016.07.019] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 06/21/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'Empowerment of communities'. To be able to empower the communities they serve, we argue, it is essential that CHWs themselves be, and feel, empowered. We present here a critique of how diverse national CHW programs affect CHW's empowerment experience. METHODS We present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used. RESULTS CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact. CONCLUSIONS While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.
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Affiliation(s)
- Sumit Kane
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Maryse Kok
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands
| | - Hermen Ormel
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands
| | - Lilian Otiso
- LVCT Health, Research and Strategic Information Department, P.O Box 19835-00202, Nairobi, Kenya
| | - Mohsin Sidat
- University Eduardo Mondlane, Department of Community Health, P.O. Box 257, Maputo, Mozambique
| | - Ireen Namakhoma
- Research for Equity and Community Health (REACH)Trust, P.O. Box 1597, Lilongwe, Malawi
| | - Sudirman Nasir
- Eijkman Institute for Molecular Biology, and Faculty of Public Health, Hasanuddin University, Makassar, Indonesia, Jalan Diponegoro 69, Jakarta, 10430, Indonesia; Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
| | | | - Sabina Rashid
- James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom
| | - Korrie de Koning
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands
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Kok MC, Ormel H, Broerse JEW, Kane S, Namakhoma I, Otiso L, Sidat M, Kea AZ, Taegtmeyer M, Theobald S, Dieleman M. Optimising the benefits of community health workers' unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries. Glob Public Health 2016; 12:1404-1432. [PMID: 27133127 DOI: 10.1080/17441692.2016.1174722] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs' relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs' relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position.
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Affiliation(s)
- Maryse C Kok
- a KIT Health , Royal Tropical Institute , Amsterdam , The Netherlands.,b Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam , Amsterdam , The Netherlands
| | - Hermen Ormel
- a KIT Health , Royal Tropical Institute , Amsterdam , The Netherlands
| | - Jacqueline E W Broerse
- b Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam , Amsterdam , The Netherlands
| | - Sumit Kane
- a KIT Health , Royal Tropical Institute , Amsterdam , The Netherlands
| | - Ireen Namakhoma
- c Research for Equity and Community Health (REACH) Trust , Lilongwe , Malawi
| | - Lilian Otiso
- d Research and Strategic Information Department , LVCT Health , Nairobi , Kenya
| | - Moshin Sidat
- e Department of Community Health , University Eduardo Mondlane , Maputo , Mozambique
| | | | - Miriam Taegtmeyer
- g Department of International Public Health , Liverpool School of Tropical Medicine , Liverpool , UK
| | - Sally Theobald
- g Department of International Public Health , Liverpool School of Tropical Medicine , Liverpool , UK
| | - Marjolein Dieleman
- a KIT Health , Royal Tropical Institute , Amsterdam , The Netherlands.,b Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam , Amsterdam , The Netherlands
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McCollum R, Otiso L, Mireku M, Theobald S, de Koning K, Hussein S, Taegtmeyer M. Exploring perceptions of community health policy in Kenya and identifying implications for policy change. Health Policy Plan 2015; 31:10-20. [PMID: 25820367 PMCID: PMC4724165 DOI: 10.1093/heapol/czv007] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2015] [Indexed: 01/13/2023] Open
Abstract
Background: Global interest and investment in close-to-community health services is increasing. Kenya is currently revising its community health strategy (CHS) alongside political devolution, which will result in revisioning of responsibility for local services. This article aims to explore drivers of policy change from key informant perspectives and to study perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change. Methods: We conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives, including those who will influence or be influenced by CHS policy change in Kenya (policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members) in two purposively selected counties: Nairobi and Kitui. Qualitative data were digitally recorded, transcribed, translated and coded before framework analysis. Results: There is widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas for change identified include: lack of clear supervisory structure including provision of adequate travel resources, current uneven coverage and equity of community health services, limited community knowledge about the strategy revision and demand for home-based HIV testing and counselling. Conclusion: This in-depth analysis which captures multiple perspectives results in robust recommendations for strategy revision informed by the Five Wonders of Change Framework. These recommendations point towards a more people-centred health system for improved equity and effectiveness and indicate priority areas for action if success of policy change through the roll-out of the revised strategy is to be realized.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK,
| | - Lilian Otiso
- Research and Strategic Information Department LVCT Health, Nairobi, Kenya
| | - Maryline Mireku
- Research and Strategic Information Department LVCT Health, Nairobi, Kenya
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Korrie de Koning
- KIT Health, Royal Tropical Institute, Amsterdam, The Netherlands, and
| | - Salim Hussein
- Community Health and Development Unit, Ministry of Health, Kenya
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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