Perspectives of community and facility stakeholders on community health workers in rural Malawi

BACKGROUND

Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household-level CHW services, in remote areas, to understand CHW's role in community-based PHC.

AIM

To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community-based PHC in Neno District.

SETTING

The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa.

METHODS

We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change.

RESULTS

Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community-based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community-based PHC.

CONCLUSION

Community health workers enrich community-based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health-seeking behaviours.Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.

Strategies for Sustained Empowerment of Community Health Workers: A Qualitative Analysis of the Comprehensive Rural Health Project in Jamkhed, India

To understand the core aspects of an empowerment-based Community Health Worker (CHW) training program, we studied the model of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India-an organization known for facilitating empowerment of women as Village Health Workers (VHWs) and agents of community change. We define empowerment as a means by which individuals gain health and development-related skills and knowledge to facilitate positive change within their lives and communities. Using VHW training observations and semi-structured interviews with health workers and senior trainers, 6 themes were developed and applied in 4 focus group sessions with 18 multigenerational VHWs trained by the CRHP. Transcripts were qualitatively analyzed under 6 themes-selection, baseline training, continuing education and support, community participation, community empowerment, and commitment and longevity. Empowerment of VHWs was found to be an intentional process involving the creation of safe and supportive environments conducive to long-term participatory and experiential learning with professionals who facilitate and mentor. The impact of the baseline training is maintained through ongoing program-VHW interactions and knowledge reinforcement in both the field and training center. Importantly, these interactions reinforce VHWs' credibility and confidence in communities served. Community participation was found to be of key importance starting at the selection phase. The methods used for selection, training and ongoing support are critical to developing a cadre of competent, effective and motivated VHWs as well as fostering long-lasting self-development and leadership skills. Downstream effectiveness of community empowerment on health outcomes is demonstrated through indicators such as access to safe deliveries, declining child malnutrition rates, high vaccination rates as well as reductions in stigmatization of illness and caste discrimination.

Supporting the Utilization of Community-Based Primary Health Care Implementation Research in Ghana

Ever since the 1990s, implementation research in Ghana has guided the development of policies and practices that are essential to establishing community-based primary health care. In response to evidence emerging from this research, the Community-based Health Planning and Services (CHPS) policy was promulgated in 1999 to scale-up results. However, during the first decade of CHPS operation, national monitoring showed that its pace of coverage expansion was unacceptably slow. In 2010, the Ghana Health Service launched a five-year plausibility trial of CHPS reform for testing ways to accelerate scale-up. This initiative, known as the Ghana Essential Health Intervention Program (GEHIP), included a knowledge management component for establishing congruence of knowledge generation and flow with the operational system that GEHIP evidence was intended to reform. Four Upper East Region districts served as trial areas while seven districts were comparison areas. Interventions tested means of developing the upward flow of information based on perspectives of district managers, sub-district supervisors, and community-level workers. GEHIP also endeavored to improve procedures for the downward flow and utilization of policy guidelines. Field exchanges were convened for providing national, regional, and district leaders with opportunities for participatory learning about GEHIP implementation innovations. This systems approach facilitated the process of augmenting the communication of evidence with practical field experience. Scientific rigor associated with the production of evidence was thereby integrated into management decision-making processes in ways that institutionalized learning at all levels. The GEHIP knowledge management system functioned as a prototype for guiding the planning of a national knowledge management strategy. A follow-up project transferred its mechanisms from the Upper East Regional Health Administration to the Policy Planning Monitoring and Evaluation Division of the Ghana Health Service in Accra.

Application of Artificial Intelligence in Community-Based Primary Health Care: Systematic Scoping Review and Critical Appraisal

BACKGROUND

Research on the integration of artificial intelligence (AI) into community-based primary health care (CBPHC) has highlighted several advantages and disadvantages in practice regarding, for example, facilitating diagnosis and disease management, as well as doubts concerning the unintended harmful effects of this integration. However, there is a lack of evidence about a comprehensive knowledge synthesis that could shed light on AI systems tested or implemented in CBPHC.

OBJECTIVE

We intended to identify and evaluate published studies that have tested or implemented AI in CBPHC settings.

METHODS

We conducted a systematic scoping review informed by an earlier study and the Joanna Briggs Institute (JBI) scoping review framework and reported the findings according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Reviews) reporting guidelines. An information specialist performed a comprehensive search from the date of inception until February 2020, in seven bibliographic databases: Cochrane Library, MEDLINE, EMBASE, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ScienceDirect, and IEEE Xplore. The selected studies considered all populations who provide and receive care in CBPHC settings, AI interventions that had been implemented, tested, or both, and assessed outcomes related to patients, health care providers, or CBPHC systems. Risk of bias was assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST). Two authors independently screened the titles and abstracts of the identified records, read the selected full texts, and extracted data from the included studies using a validated extraction form. Disagreements were resolved by consensus, and if this was not possible, the opinion of a third reviewer was sought. A third reviewer also validated all the extracted data.

RESULTS

We retrieved 22,113 documents. After the removal of duplicates, 16,870 documents were screened, and 90 peer-reviewed publications met our inclusion criteria. Machine learning (ML) (41/90, 45%), natural language processing (NLP) (24/90, 27%), and expert systems (17/90, 19%) were the most commonly studied AI interventions. These were primarily implemented for diagnosis, detection, or surveillance purposes. Neural networks (ie, convolutional neural networks and abductive networks) demonstrated the highest accuracy, considering the given database for the given clinical task. The risk of bias in diagnosis or prognosis studies was the lowest in the participant category (4/49, 4%) and the highest in the outcome category (22/49, 45%).

CONCLUSIONS

We observed variabilities in reporting the participants, types of AI methods, analyses, and outcomes, and highlighted the large gap in the effective development and implementation of AI in CBPHC. Further studies are needed to efficiently guide the development and implementation of AI interventions in CBPHC settings.

Capacity building and mentorship among pan-Canadian early career researchers in community-based primary health care

AIM

To describe activities and outcomes of a cross-team capacity building strategy that took place over a five-year funding period within the broader context of 12 community-based primary health care (CBPHC) teams.

BACKGROUND

In 2013, the Canadian Institutes of Health Research funded 12 CBPHC Teams (12-Teams) to conduct innovative cross-jurisdictional research to improve the delivery of high-quality CBPHC to Canadians. This signature initiative also aimed to enhance CBPHC research capacity among an interdisciplinary group of trainees, facilitated by a collaboration between a capacity building committee led by senior researchers and a trainee-led working group.

METHODS

After the committee and working group were established, capacity building activities were organized based on needs and interests identified by trainees of the CBPHC Teams. This paper presents a summary of the activities accomplished, as well as the outcomes reported through an online semistructured survey completed by the trainees toward the end of the five-year funding period. This survey was designed to capture the capacity building and mentorship activities that trainees either had experienced or would like to experience in the future. Descriptive and thematic analyses were conducted based on survey responses, and these findings were compared with the existing core competencies in the literature.

FINDINGS

Since 2013, nine webinars and three online workshops were hosted by trainees and senior researchers, respectively. Many of the CBPHC Teams provided exposure for trainees to innovative methods, CBPHC content, and showcased trainee research. A total of 27 trainees from 10 of the 12-Teams responded to the survey (41.5%). Trainees identified key areas of benefit from their involvement in this initiative: skills training, networking opportunities, and academic productivity. Trainees identified gaps in research and professional skill development, indicating areas for further improvement in capacity building programs, particularly for trainees to play a more active role in their education and preparation.

Community perceptions of universal health coverage in eight districts of the Northern and Volta regions of Ghana

Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving 'Health for All.' The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana's flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services.Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved.Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15-24.Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women's health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services.Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal.

An extension of the Alma-Ata vision for primary health care in light of twenty-first century evidence and realities

This paper builds upon and extends the definition of primary health care in the 1978 Declaration of Alma-Ata. The definition proposes a stronger role for community-based delivery of services and community mobilization, participation and empowerment. It calls for a stronger integration with vertical, disease-specific programs. And, finally, it calls for a strong role for certain curative services (including basic and essential surgery) that many today would not consider as part of primary health care. There is growing evidence that communities can and should play a stronger role than has traditionally been the case, that community-level workers who are properly trained and supported can provide effective services outside of health facilities, and that primary health centers staffed with non-specialist physicians and even non-physician clinicians can perform many of the lower-level inpatient services now performed at first-level referral hospitals. An approach to primary health care that is appropriate to the local context and that merges local epidemiological priorities with the communities' perceived priorities will make it possible to engage communities as partners. Currently, essential and basic health care services are available to only one-half of the world's population. The full development of primary health care as envisioned here will accelerate progress in achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978.

Are Patient and Carer Experiences Mirrored in the Practice Reviews of Self-management Support (Prisms) Provider Taxonomy?

Introduction:

Patient self-management support is central to care for long term conditions and for integrated care. Patients and their carers are the final arbiter of whether support for self-management has been effective. A new taxonomy lists 14 categories of provider activities that support patient self-management (Practical Reviews in Self-Management Support, PRISMS). We asked whether we could recognise these provider activities in narratives from patients and carers. We sought to extend the theoretical framework of the taxonomy to include the view from patient and carers.

Methods:

We interviewed 28 patients and family carers in a case study of primary health care in New Zealand in 2015 to determine which components of the taxonomy were visible. We drew on interviews with clinicians and organisation persons to explain case study context.

Results:

We found, within patient and carer data, evidence of all 14 components of provider self-management support. The overarching dimensions of the taxonomy helped reveal an intensity and consistency of provider behaviour that was not apparent considering the individual components.

Conclusions:

Patient and carer data mapped to provider activities. The taxonomy was not explicit on provider relationships and engagement with, or separate support needs of, patients and carers.

How do Policy and Institutional Settings Shape Opportunities for Community-Based Primary Health Care? A Comparison of Ontario, Québec and New Zealand

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the 'space available' for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the 'barbed-wire fence' that separates funding of medical and 'non-medical' primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence.

Barriers to implementation of case management for patients with dementia: a systematic mixed studies review

PURPOSE

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation.

METHODS

We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers.

CONCLUSIONS

Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.