Improving skills and utilization of community health volunteers in Nepal

An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change

BACKGROUND

Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).

METHODS

We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.

RESULTS

Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.

CONCLUSIONS

Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.

Identifying Programmatic Factors that Increase Likelihood of Health Facility Delivery: Results from a Community Health Worker Program in Zanzibar

INTRODUCTION

Community health worker (CHW) interventions have been utilized to address barriers that prevent pregnant women from delivering in health facilities in low- and middle-income countries (LMICs). The objective of this research was to assess the programmatic factors that increase the likelihood of health facility delivery within a large digital health-supported CHW program in Zanzibar, Tanzania.

METHODS

This study included 36,693 women who were enrolled in the Safer Deliveries program with a live birth between January 1, 2017 and July 31, 2019. We assessed whether long-term enrollment, recency of CHW pregnancy visit prior to delivery, and number of routine home pregnancy visits were associated with an increased likelihood of health facility delivery compared to home delivery. We used Chi-squared tests to assess bivariate relationships and performed logistic regression analyses to assess the association between each programmatic variable and health facility delivery, adjusting for relevant confounders.

RESULTS

We found that long-term enrollment was significantly associated with increased likelihood of health facility delivery, with the strongest relationship among women with a previous home delivery (OR = 1.4, 95%CI [1.0,1.7]). Among first-time mothers, two or more pregnancy visits by a CHW was positively associated with health facility delivery (OR = 1.8, 95%CI [1.2, 2.7]). Recent pregnancy visit by a CHW was positively associated with health facility delivery, but was not significant at the α = 0.05 level.

DISCUSSION

In this program, we found evidence that at least two routine home pregnancy visits, longer length of enrollment in the program, and recency of home visit to the delivery date were strategies to increase health facility delivery rates among enrolled mothers. Maternal and child health programs should undertake similar evaluations to improve program delivery.

Role of female community health volunteers in ischemic stroke prevention, identification, referral and rehabilitation in Nepal

For the past three decades, female community health volunteers (FCHVs) have been at the forefront of Nepal's health map and have contributed significantly to its improving health indicators such as maternal mortality rate and infant mortality rate. Given the changing epidemiology of Nepal and the shift of burden from communicable to non-communicable diseases (NCDs), it is important to revitalize their role with the changing times. The prevalence of ischemic stroke in Nepal is on the rise. However, very few people make it to the hospital within the time frame for thrombolysis and the patient's knowledge about ischemic stroke seems to play a major part. FCHVs can play a significant role in improving ischemic stroke care by raising awareness about the condition, its risk factors, and informing the public about the need for timely treatment. They can help screen for common risk factors such as obesity, hypertension and diabetes as well as monitor for treatment in previously diagnosed individuals. Randomized controlled trials have shown to yield favorable results in NCDs with engagement of FCHVs. With proper training and support, they can play an important role in improving ischemic stroke care in low- and middle-income countries like Nepal.

Integrated community case management of childhood illness in low- and middle-income countries

BACKGROUND

The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012).

OBJECTIVES

To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison.

AUTHORS' CONCLUSIONS

iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.

Work environment factors and provider performance in health houses: a case study of a developing country

Objective

Primary Health Care has determined the path to the goal of "Health for All". Defining standards in health facilities play a crucial role in achieving acceptable performance by Community Health Workers. The study aimed to assess the relationship between physical Work environment factors and performance in primary healthcare facilities named health houses in Urmia district health network in North West of Iran. Thirty-five health houses were selected and studied with simple random sampling method. Data collection instrument were a standard checklist.

Results

The results highlighted a statistically significant and positive correlation between technical equipment layout (P = 0.01, r = 0.641) with the performance of CHWs and the area of workplace (P = 0.05, r = 0.359) in health houses. Correlation between office equipment layout and performance was negative (P = 0.01, r = − 0.44). Multiple linear regression analysis showed that the performance level was influenced by the staff-mix of CHWs in health houses, layout of technical equipment and layout of office equipment.

Role-play versus lecture methods in community health volunteers

BACKGROUND

Considering the key role of health volunteers in promoting community's health, their effective training is of particular importance. Training can be more effective through cooperative and learner-centered methods. Role-play is among the cooperative methods with numerous advantages. Considering the positive impact of training via various methods, we aimed to compare training through role-play and lecture on health volunteers' health knowledge in selected comprehensive health centers of Shiraz, Iran.

METHODS

This quasi-experimental study was conducted on all health volunteers in four comprehensive health centers selected via random cluster sampling during the second half of 2017. The participants were divided into intervention and control groups and took part in the pretest based on the book entitled "Promotion of Breastfeeding". Based on the pretest results, health volunteers trained the participants in three educational sessions. The two groups were evaluated again immediately and two months after the intervention.

RESULTS

The mean age of the participants was 49.97 ± 8.1 and 46.52 ± 10.74 years in intervention and control groups, respectively. Most participants were married (94.8%) and had diplomas (92.1%).A significant difference was seen between both groups in knowledge scores at the three time points (P < 0.001). A significant difference was found between the two groups regarding knowledge scores immediately and two months after the intervention (P < 0.001), indicating the effectiveness of training through role-play.

CONCLUSION

The advantages of role-play, including development of communication skills and active listening, resulted in the learners' enthusiasm and motivation. This method was accompanied with higher educational output as well as longer knowledge persistence. Role-play increased cooperation and group discussions performed after the role-play promoted the transfer emotional experiences.

Perceived barriers to accessing Female Community Health Volunteers' (FCHV) services among ethnic minority women in Nepal: A qualitative study

Despite the efforts of community health workers to increase access to healthcare among ethnic minority groups in low- and -middle income countries, members of ethnic minorities are less likely than women from other ethnic groups to use maternal and child healthcare services. However, much less is known about the factors that limit access of ethnic minorities to healthcare services, including the services of community health workers in Nepal, who are known as Female Community Health Volunteers (FCHVs). To address this issue, we conducted a qualitative study to explore perceived barriers to accessing maternal and child healthcare services among ethnic minority groups in two different geographical locations (the hill and Terai regions- flatland bordering south India) with varying degrees of access to local healthcare centres. Between April 2014 and September 2014, semi-structured interviews were conducted with twenty FCHVs, 26 women service users and 11 paid local health workers. In addition, 15 FCHVs participated in four focus group discussions. A thematic analysis of the data identified five major themes underlying barriers to accessing available maternal and child healthcare services by ethnic minority groups such as Dalits, Madhesi, Muslim, Chepang and Tamang. These themes include: a) lack of knowledge among service users; b) lack of trust in volunteers; c) traditional beliefs and healthcare practices; d) low decision-making power of women; and e) perceived indignities experienced when using health centres. We conclude that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups, and the programmes should involve family members (husband and mothers-in-law) and traditional health practitioners. Both the FCHVs and local healthcare providers should be trained to communicate effectively in order to deliver respectful care among ethnic minorities if we want to achieve universal healthcare coverage for maternal and child health in low- and -middle income countries.

Telemedicine Training and Support for Community Health Workers: Improving Knowledge of Diabetes

Background: Community health workers (CHWs) are a well-established source to improve patient health care, yet their training and support remain suboptimal. This limits program expansion and potentially compromises patient safety. The objective of the study was to evaluate the feasibility and acceptability of weekly training and support by telemedicine (videoconferencing). Materials and Methods: CHWs (n = 6) who led diabetes group visits for low-income Latinos met weekly with a health care professional for training and support. Feasibility and acceptability outcome measures included telemedicine usability, knowledge of diabetes (baseline to 6 months), and program satisfaction. Results: Telemedicine training and support were found to be feasible and acceptable as measured by usability (Telehealth Usability Questionnaire: average 4.7/5.0, ±0.4), knowledge (Diabetes Knowledge Test: pretest 15.8 ± 1.3, posttest 21.8 ± 1.2, p < 0.001, respectively), and satisfaction (Texas Department of State Health Services survey: average 5.8/6.0, ±0.5). All CHWs preferred telemedicine to in-person training. Conclusions: Telemedicine is a feasible and acceptable modality to train and support CHWs.

The salt between the beans: a qualitative study of the role of auxiliary midwives in a hard-to-reach area of Myanmar

Background

Auxiliary Midwives (AMWs) are unpaid volunteer health workers assisting qualified paid midwives in maternal and child health care mainly in hard-to-reach areas of Myanmar. This paper describes the relationship between AMWs and the health system in providing maternal and child services as perceived by the community, AMWs themselves and health care providers in one remote township of Myanmar.

Method

A qualitative study was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, AMWs, community members and mothers were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. Thematic analysis was done using the ATLAS.ti software.

Results

AMWs occupy a unique position between the community and the health sector in the study township. The relationship and trust with the community is built upon prolonged presence providing health care, skill building and fulfilling community expectations. Health care providers’ expectations to provide only preventive care, health promotion and education and childbirth care are often exceeded in reality when emergencies occur in hard-to-reach areas. This challenge to handle emergency situations with no support and limited skills and training is considered as most difficult by the AMWs. This mismatch of service provision expectations by both the community and other health care providers has put AMWs in a position which they describe as being the “salt between the beans” an essential ingredient but often invisible between the beans.

Conclusion

The trust and relationship developed by AMWs over four decades of community practice serving as the mediator role is an untapped resource that can facilitate future community-based maternal and child health interventions in Myanmar.

Volunteering for Health Services in the Middle Part of Ghana: In Whose Interest?

BACKGROUND

In many developing countries like Ghana, community volunteers assist in the provision of certain health services to rural and hard-to-reach communities. This study examined factors that influence the motivation and retention of community-based volunteers supporting with work on health-related activities at the community level in Ghana.

METHODS

Using a sequential mixed-method design, a cross-sectional survey was carried out among 205 selected community-based volunteers in Kintampo North Municipality (KNM) and Kintampo South District (KSD) of Ghana between December, 2014 and February, 2015. Qualitative interviews, including 12 in-depth interviews (IDIs) among health workers and community opinion leaders and 2 focus group discussion (FGD) sessions with volunteers were conducted.

RESULTS

Personal interest (32.7%) and community leaders' selection of volunteers (30.2%) were key initial reasons for volunteering. Monetary incentives such as allowance for extra duty (88.8%) and per diem (49.3%) and non-monetary incentives such as T-shirts/bags (45.4 %), food during training (52.7%), community recognition, social prestige and preferential treatment at health facilities were the facilitators of volunteers' retention. There was a weak evidence (P=.051) to suggest that per diem for their travels is a reason for volunteers' satisfaction.

CONCLUSION

Community-based volunteers' motivation and retention were influenced by their personal interest in the form of recognition by community members and health workers, community leaders' selection and other nonmonetary incentives. Volunteers were motivated by extra-duty allowance but not per diems paid for accommodation and feeding when they travel. Organizations that engage community volunteers are encouraged to strengthen the selection of volunteers in collaboration with community leaders, and to provide both non-monetary and monetary incentives to motivate volunteers.

'MATRI-SUMAN' a capacity building and text messaging intervention to enhance maternal and child health service utilization among pregnant women from rural Nepal: study protocol for a cluster randomised controlled trial

BACKGROUND

Capacity development of health volunteers and text messaging to pregnant women through mobile phones have shown improved maternal and child health (MCH) outcomes and is associated with increased utilisation of MCH services. However, such interventions are uncommon in Nepal. We aim to carry out an intervention with the hypothesis that capacity building and text messaging intervention will increase the MCH service utilisation.

METHOD/DESIGN

MATRI-SUMAN is a 12-month cluster randomized controlled trial (RCT). The trial involves pregnant women from 52 clusters of six village development committees (VDCs) covering 66,000 populations of Dhanusha district of Nepal. In the intervention clusters, Female Community Health Volunteers (FCHVs) will receive capacity development skills through reinforcement training, supervision and monitoring skills for the promotion of health seeking behaviour among pregnant women and study participants will receive periodic promotional text messaging service about MCH components through mobile phones. A sample of 354with equal numbers in each study arm is estimated using power calculation formula. The primary outcomes of this study are the rate of utilization of skilled birth attendants and consumption of a specified diversified meal. The secondary outcomes are: four antenatal (ANC) visits, weight gain of women during pregnancy, delivery of a baby at the health facility, postnatal care (PNC) visits, positive changes in child feeding practices among mothers, performance of FCHVs in MCH service utilization.

DISCUSSION

The intervention is designed to enhance the capacity of health volunteers for the promotion of health seeking behaviour among pregnant women and text messaging through a mobile phone to expecting mothers to increase MCH service utilization. The trial if proven effective will have policy implications in poor resource settings.

TRIAL REGISTRATION

ISRCTN60684155, ( https://doi.org/10.1186/ISRCTN60684155 ). The trial was registered retrospectively.

The roles, training and knowledge of community health workers about diabetes and hypertension in Khayelitsha, Cape Town

BACKGROUND

 The current roles and capacity of community health workers (CHWs) in the management and control of non-communicable diseases (NCDs) remain poorly understood.

OBJECTIVES

 To assess CHWs' current roles, training and knowledge about diabetes and hypertension in Khayelitsha, Cape Town.

METHODS

 A cross-sectional study of 150 CHWs from two non-governmental organisations contracted to provide NCD care as part of a comprehensive package of services was conducted. An interviewer-administered closed-ended questionnaire was used to determine the roles, training, in-service support, knowledge and presence of NCDs. Descriptive analyses of these domains and multivariate analyses of the factors associated with CHWs' knowledge of hypertension and diabetes were conducted.

RESULTS

 The vast majority (96%) of CHWs were female, with a mean age of 35 years; 88% had some secondary schooling and 53% had been employed as CHWs for 4 years or more. Nearly half (47%) reported having an NCD. CHWs' roles in NCDs included the delivery of medication, providing advice and physical assessment. Only 52% of CHWs reported some formal NCD-related training, while less than half of the trained CHWs (n = 35; 44%) had received follow-up refresher training. CHWs' knowledge of diabetes and hypertension was poor. In the multivariate analyses, higher knowledge scores were associated with having an NCD and frequency of supervisory contact (≥1 per month).

CONCLUSIONS

 The roles performed by CHWs are broad, varied and essential for diabetes and hypertension management. However, basic knowledge about diabetes and hypertension remains poor while training is unstandardised and haphazard. These need to be improved if community-based NCD management is to be successful. The potential of peer education as a complementary mechanism to formal training needs as well as support and supervision in the workplace requires further exploration.

The contribution of female community health volunteers (FCHVs) to maternity care in Nepal: a qualitative study

Background

In resource-poor settings, the provision of basic maternity care within health centres is often a challenge. Despite the difficulties, Nepal reduced its maternal mortality ratio by 80% from 850 to an estimated 170 per 100,000 live births between 1991 and 2011 to achieve Millennium Development Goal Five. One group that has been credited for this is community health workers, known as Female Community Health Volunteers (FCHVs), who form an integral part of the government healthcare system. This qualitative study explores the role of FCHVs in maternal healthcare provision in two regions: the Hill and Terai.

Methods

Between May 2014 and September 2014, 20 FCHVs, 11 health workers and 26 service users were purposefully selected and interviewed using semi-structured topic guides. In addition, four focus group discussions were held with 19 FCHVs. Data were analysed using thematic analysis.

Results

All study participants acknowledged the contribution of FCHVs in maternity care. All FCHVs reported that they shared key health messages through regularly held mothers’ group meetings and referred women for health checks. The main difference between the two study regions was the support available to FCHVs from the local health centres. With regular training and access to medical supplies, FCHVs in the hill villages reported activities such as assisting with childbirth, distributing medicines and administering pregnancy tests. They also reported use of innovative approaches to educate mothers. Such activities were not reported in Terai. In both regions, a lack of monetary incentives was reported as a major challenge for already overburdened volunteers followed by a lack of education for FCHVs.

Conclusions

Our findings suggest that the role of FCHVs varies according to the context in which they work. FCHVs, supported by government health centres with emphasis on the use of local approaches, have the potential to deliver basic maternity care and promote health-seeking behaviour so that serious delays in receiving healthcare can be minimised. However, FCHVs need to be reimbursed and provided with educational training to ensure that they can work effectively. The study underlines the relevance of community health workers in resource-poor settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2567-7) contains supplementary material, which is available to authorized users.

Female Community Health Volunteers in Community-Based Health Programs of Nepal: Future Perspective

Nepal’s Female Community Health Volunteers (FCHVs) program started in 1988. In the early years of program initiation, FCHVs were assigned to promote and distribute the family planning commodities such as condoms and pills. Over past three decades, FCHVs’ roles have gradually expanded beyond family planning program and especially are focused on maternal and child health services at a large scale. FCHVs are an integral part of many community-based health programs, and their roles are instrumental in linking families and communities to community health workers and periphery-level health facilities. However, the fragmented nature of health programs poses a challenge for these health volunteers to coordinate activities and deliver the results. This perspective aims to review their contribution, challenges and recommend an integrated FCHV program model to support in the implementation of the community-based health interventions effectively.

Assessment of the impact of quality improvement interventions on the quality of sick child care provided by Health Extension Workers in Ethiopia

Background

Ethiopia has scaled up integrated community case management of childhood illness (iCCM), including several interventions to improve the performance of Health Extension Workers (HEWs). We assessed associations between interventions to improve iCCM quality of care and the observed quality of care among HEWs.

Methods

We assessed iCCM implementation strength and quality of care provided by HEWs in Ethiopia. Multivariate logistic regression analyses were performed to assess associations between interventions to improve iCCM quality of care and correct management of iCCM illnesses.

Findings

Children who were managed by an HEW who had attended a performance review and clinical mentoring meeting (PRCMM) had 8.3 (95% confidence interval (CI) 2.34–29.51) times the odds of being correctly managed, compared to children managed by an HEW who did not attend a PRCMM. Management by an HEW who received follow–up training also significantly increased the odds of correct management (odds ratio (OR) = 2.09, 95% CI 1.05–4.18). Supervision on iCCM (OR = 0.63, 95% CI 0.23–1.72) did not significantly affect the odds of receiving correct care.

Conclusions

These results suggest PRCMM and follow–up training were effective interventions, while implementation of supportive supervision needs to be reviewed to improve impact.

Mother-to-mother therapy in India and Pakistan: adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme

BACKGROUND

Perinatal depression is highly prevalent in South Asia. Although effective and culturally feasible interventions exist, a key bottleneck for scaled-up delivery is lack of trained human resource. The aim of this study was to adapt an evidence-based intervention so that local women from the community (peers) could be trained to deliver it, and to test the adapted intervention for feasibility in India and Pakistan.

METHODS

The study was conducted in Rawalpindi, Pakistan and Goa, India. To inform the adaptation process, qualitative data was collected through 7 focus groups (four in Pakistan and three in India) and 61 in-depth interviews (India only). Following adaptation, the intervention was delivered to depressed mothers (20 in Pakistan and 24 in India) for six months through 8 peers in Pakistan and nine in India. Post intervention data was collected from depressed mothers and peers through 41 in-depth interviews (29 in Pakistan and 12 in India) and eight focus groups (one in Pakistan and seven in India). Data was analysed using Framework Analysis approach.

RESULTS

Most mothers perceived the intervention to be acceptable, useful, and viewed the peers as effective delivery-agents. The simple format using vignettes, pictures and everyday terms to describe distress made the intervention easy to understand and deliver. The peers were able to use techniques for behavioural activation with relative ease. Both the mothers and peers found that shared life-experiences and personal characteristics greatly facilitated the intervention-delivery. A minority of mothers had concerns about confidentiality and stigma related to their condition, and some peers felt the role was emotionally challenging.

CONCLUSIONS

The study demonstrates the feasibility of using peers to provide interventions for perinatal depression in two South Asian settings. Peers can be a potential resource to deliver evidence-based psychosocial interventions.

TRIAL REGISTRATION

Pakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014), India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014).

Eco-social and behavioural determinants of diarrhoea in under-five children of Nepal: a framework analysis of the existing literature

Background

While diarrhoea is the second major killer among the under-five children in the world with an estimation of 760,000 deaths annually, it stands as a major killer in Nepal with an annual incidence of 500 per 1000 under-five children with diarrhoea. Diarrhoea is responsible for a wide range of morbidity and mortality among children in Nepal. The objective of this review work is to identify the eco-social and behavioural determinants of diarrhoea among the under-five children of Nepal.

Methods

A literature review was conducted using the Dahlgren and Whitehead model (1991) between June and October 2015. PubMed, Nepal Journals online and Google Scholar were used to search for literature published between 1989 and July 2015 using defined keywords.

Results

Children of age group 6–23 months are at higher risk, as supplementary diets are introduced to the children from the age of 6 months. Male children have better access to healthcare services. Malnourished children also have a higher chance of developing persistent diarrhoea. Provision of safe water and sanitation has direct link with the prevention and control of diarrhoea. Male gender with high income positively influences the treatment-seeking behaviour. Mother’s education and hand-washing practice have direct influence in child health. Hand-washing practices with soap which are protective are influenced by the cultural beliefs. Involvement of community health volunteers increases the access to the health system, thereby reducing the diarrhoeal burden in the community.

Conclusion

Age, gender, hand-washing behaviour, nutritional status of children, education of mothers, water and sanitation, healthcare services, cultural and societal values and income of the household were identified determinants for diarrhoea in under-five children of Nepal.

Assessing the Quality of Care for Pneumonia in Integrated Community Case Management: A Cross-Sectional Mixed Methods Study

Background

Pneumonia is the leading infectious cause of mortality in children under five worldwide. Community-level interventions, such as integrated community case management, have great potential to reduce the burden of pneumonia, as well as other diseases, especially in remote populations. However, there are still questions as to whether community health workers (CHW) are able to accurately assess symptoms of pneumonia and prescribe appropriate treatment. This research addresses limitations of previous studies using innovative methodology to assess the accuracy of respiratory rate measurement by CHWs and provides new evidence on the quality of care given for children with symptoms of pneumonia. It is one of few that assesses CHW performance in their usual setting, with independent re-examination by experts, following a considerable period of time post-training of CHWs.

Methods

In this cross-sectional mixed methods study, 1,497 CHW consultations, conducted by 90 CHWs in two districts of Luapula province, Zambia, were directly observed, with measurement of respiratory rate for children with suspected pneumonia recorded by video. Using the video footage, a retrospective reference standard assessment of respiratory rate was conducted by experts. Counts taken by CHWs were compared against the reference standard and appropriateness of the treatment prescribed by CHWs was assessed. To supplement observational findings, three focus group discussions and nine in depth interviews with CHWs were conducted.

Results and Conclusion

The findings support existing literature that CHWs are capable of measuring respiratory rates and providing appropriate treatment, with 81% and 78% agreement, respectively, between CHWs and experts. Accuracy in diagnosis could be strengthened through further training and the development of improved diagnostic tools appropriate for resource-poor settings.

Health workers' and managers' perceptions of the integrated community case management program for childhood illness in Malawi: the importance of expanding access to child health services

Community case management (CCM) is a promising task-shifting strategy for expanding treatment of childhood illness that is increasingly adopted by low-income countries. Its success depends in part on how the strategy is perceived by those responsible for its implementation. This study uses qualitative methods to explore health workers' and managers' perceptions about CCM provided by health surveillance assistants (HSAs) during the program's first year in Malawi. Managers and HSAs agreed that CCM contributed beneficially by expanding access to the underserved and reducing caseloads at health facilities. Managers differed among themselves in their endorsements of CCM, most offered constrained endorsement, and a few had stronger justifications for CCM. In addition, HSAs uniformly wanted continued expansion of their clinical role, while managers preferred to view CCM as a limited mandate. The HSAs also reported motivating factors and frustrations related to system constraints and community pressures related to CCM. The impact of CCM on motivation and workload of HSAs is noted and deserves further attention.

Insights from community case management data in six sub-Saharan African countries

There is strong research evidence that community case management (CCM) programs can significantly reduce mortality. There is less evidence, however, on how to implement CCM effectively either from research or regular program data. We analyzed monitoring data from CCM programs supported by the International Rescue Committee (IRC), covering over 2 million treatments provided from 2004 to 2011 in six countries by 12,181 community health workers (CHWs). Our analysis yielded several findings of direct relevance to planners and managers. CCM programs seem to increase access to treatment, although diarrhea coverage remains low. In one country, the size of the catchment area was correlated with use, and increased supervision was temporally and strongly associated with improved quality. Planners should use routine data to guide CCM program planning. Programs should treat all three conditions from the outset. Other priorities should include use of diarrhea treatment and insurance of adequate supervision.

Community health workers: to train or to restrain? A longitudinal survey to assess the impact of training community health workers in the Bolama Region, Guinea-Bissau

BACKGROUND

The shortage in human resources for health affects most dramatically developing countries which frequently use community health workers (CHW) as the basis for health programmes and services. The traditional definition refers CHWs as members of the community who are recruited and trained in health prevention and promotion to provide services within their community. In Guinea-Bissau, CHWs play a fundamental role in the diagnosis and treatment of childhood diarrheal diseases - one of the main health problems in the country.

METHODS

This study is based on 22 CHW, 79% of the total number of CHW in the Sanitary Region of Bolama. The main goal was to assess how training CHW on diarrheal diseases impacted the accuracy of the diagnosis and treatment of these diseases in children under the age of 5 years. Three evaluations were made throughout time - one evaluation before the training and two follow-up evaluations.An observation grid was developed to evaluate the identified signs, symptoms, diagnosis and treatments prescribed by the CHW in consultations to children with a suspicion of diarrhoeal disease. A similar grid was filled by a medical doctor who took the role of the external validation standard.Friedman's variance analysis and Cochran's Q test were performed to compare the accuracy depicted by CHWs in identifying items throughout time. A logistic regression model was also used to check the possible influence of socio-demographic characteristics of CHWs on the accuracy of the diagnosis and treatment prescribed by the CHW.

RESULTS

The results show that CHWs improve significantly their performance in identifying the correct diagnosis in the first follow-up moment after the training (P = 0.001, n = 22) but, 3 months later, the effectiveness decreases. No statistical evidence was found for the logistic regression models applied. This progressive loss of performance after training may occur because CHWs fail to apply treatment algorithms and guidelines over time. A limited set of socio-demographic characteristics of the CHWs can influence their performance and should not be disregarded when selecting CHW candidates.

CONCLUSION

The selection, supervision, support and continuous training of CHW are as important as the training provided.

'Sometimes they fail to keep their faith in us': community health worker perceptions of structural barriers to quality of care and community utilisation of services in Bangladesh

Community health workers (CHWs) have strong potential to extend health and nutrition services to underserved populations. However, CHWs face complex challenges when working within weak health systems and among communities with limited abilities to access and utilise CHW services. It is crucial to understand these challenges to improve programme support mechanisms. This study describes the results of qualitative investigations into CHW perceptions of barriers to quality of care among two groups of workers implementing community case management of acute respiratory infection, diarrhoea and severe acute malnutrition in southern Bangladesh. We explored systemic barriers to service delivery, pertaining to communities and health systems, which limited the usefulness and effectiveness of CHW services. Focus group discussions (n = 10) were conducted in March 2010. Discussions were analysed for themes related to CHWs' work challenges. Findings highlight several perceived barriers to effective service provision, including community poverty constraining uptake of recommended practices, irregular supplies of medicine from the health facility and poor quality of care for CHW referrals sent there. This study further documents interactions between demand-side and supply-side constraints including the influence of health system resource constraints on community trust in CHW services, and the influence of community resource constraints on the utilisation and effectiveness of CHW services. By documenting service delivery challenges from the perspective of the frontline workers themselves, this article contributes evidence to help identify appropriate support mechanisms for these workers, in order to develop scalable and sustainable CHW programmes in countries with under-resourced public health care infrastructure.

Poor retention does not have to be the rule: retention of volunteer community health workers in Uganda

Globally, health worker shortages continue to plague developing countries. Community health workers are increasingly being promoted to extend primary health care to underserved populations. Since 2004, Healthy Child Uganda (HCU) has trained volunteer community health workers in child health promotion in rural southwest Uganda. This study analyses the retention and motivation of volunteer community health workers trained by HCU. It presents retention rates over a 5-year period and provides insight into volunteer motivation. The findings are based on a 2010 retrospective review of the community health worker registry and the results of a survey on selection and motivation. The survey was comprised of qualitative and quantitative questions and verbally administered to a convenience sample of project participants. Between February 2004 and July 2009, HCU trained 404 community health workers (69% female) in 175 villages. Volunteers had an average age of 36.7 years, 4.9 children and some primary school education. Ninety-six per cent of volunteer community health workers were retained after 1 year (389/404), 91% after 2 years (386/404) and 86% after 5 years (101/117). Of the 54 ‘dropouts’, main reasons cited for discontinuation included ‘too busy’ (12), moved (11), business/employment (8), death (6) and separation/divorce (6). Of 58 questionnaire respondents, most (87%) reported having been selected at an inclusive community meeting. Pair-wise ranking was used to assess the importance of seven ‘motivational factors’ among respondents. Those highest ranked were ‘improved child health’, ‘education/training’ and ‘being asked for advice/assistance by peers’, while the modest ‘transport allowance’ ranked lowest. Our findings suggest that in our rural, African setting, volunteer community health workers can be retained over the medium term. Community health worker programmes should invest in community involvement in selection, quality training, supportive supervision and incentives, which may promote improved retention.

Does greater workload lead to reduced quality of preventive and curative care among community health workers in Bangladesh?

BACKGROUND

Community health workers (CHWs) perform a range of important tasks; however, limited evidence is available regarding the association between their workload and the quality of care they provide.

OBJECTIVE

To analyze the quality of preventive and curative care provided by two groups of CHWs with different workloads in southern Bangladesh.

METHODS

One group of CHWs provided preventive care in addition to implementing community case management (CCM) of acute respiratory infection and diarrhea, and another group additionally treated severe acute malnutrition (SAM). Preventive care was measured by case management observation at a routine household visit. Curative care was measured by case scenarios. Qualitative methods were used to contextualize CHWs' performance by examining their perceptions of challenges related to their workload. A total of 338 CHWs were assessed.

RESULTS

CHWs managing cases of SAM worked significantly more hours than the other group (16.7 +/- 6.9 hours compared with 13.3 +/- 4.6 hours weekly, p < .001) but maintained quality of care on curative and preventive work tasks. Effectively treating cases of SAM appeared to motivate CHWs.

CONCLUSIONS

This was one of the first trials adding the treatment of SAM to a CHW workload and suggests that adding SAM to a well-trained and supervised CHW's workload, including preventive and curative tasks, does not necessarily yield lower quality of care. However, increased workloads had consequences for CHWs' domestic life, and further increases in workload may not be possible without additional incentives.

Promoting community knowledge and action for malaria control in rural Cambodia: potential contributions of Village Malaria Workers

Background

Cambodia has been investing in Village Malaria Workers (VMWs) to improve malaria case management in rural areas. This study assessed the quality of the VMWs’ services compared to those by a government-run health center from the perspective of community members. We focused on VMWs’ contribution to promote their action to control malaria. A community-based cross-sectional study was conducted in Kampot province in 2009. Interviews were conducted at every accessible household in a village with VMWs (n = 153) and a village with a health center (n = 159), using interviewer administered questionnaire. Preference of the interview was given to female household head. Multiple regression analyses were run to compare knowledge about malaria, preventive measures taken, and time before first malaria treatment between the two villages.

Findings

The villagers perceived the VMWs’ services equally as good as those provided by the health center. After controlling for confounding factors, the following indicators did not show any statistical significance between two villages: community members’ knowledge about malaria transmission (AOR = 0.60, 95% CI = 0.30-1.22) and government-recommended antimalarial (AOR = 0.55, 95% CI = 0.25-1.23), preventive measures taken (Beta = −0.191, p = 0.315), and time before the first treatment (Beta = 0.053, p = 0.721). However, knowledge about malaria symptoms was significantly lower in the village with VMWs than the village with a health center (AOR = 0.40, 95% CI = 0.19-0.83).

Conclusions

VMWs played an equivalent role as the health center in promoting malaria knowledge, action, and effective case management. Although VMWs need to enhance community knowledge about malaria symptoms, the current government policy on VMWs is reasonable and should be expanded to other malaria endemic villages.

Managerial supervision to improve primary health care in low- and middle-income countries

BACKGROUND

Primary healthcare (PHC) workers often work alone or in isolation. Healthcare managerial supervision is recommended to help assure quality; but this requires skilled supervisors and takes time and resources. It is therefore important to assess to what extent supervision is beneficial and the ways in which it can be implemented.

OBJECTIVES

To review the effects of managerial supervision of health workers to improve the quality of PHC (such as adherence to guidance or coverage of services) in low- and middle-income countries.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) 2011, Issue 1, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 March 2011); MEDLINE, Ovid 1950 to March Week 1 2011 (searched 08 March 2011); EMBASE, Ovid 1980 to 2011 Week 12 (searched 08 March 2011); CINAHL, Ebsco 1981 - present (searched 10 March 2011); LILACS, VHL (searched 10 March 2011).

SELECTION CRITERIA

Randomised controlled trials, controlled before-and-after studies, and interrupted time series studies, conducted in PHC in low- and middle-income countries. Supervision includes site visits from a central level of the health system, plus at least one supervisory activity. We excluded studies aimed solely at improving the clinical skills of PHC workers.

DATA COLLECTION AND ANALYSIS

We extracted data using a predefined form and assessed for risk of bias using the EPOC risk of bias criteria. Data are presented in a narrative way without pooling the effects on the outcomes as studies and outcomes were diverse.

MAIN RESULTS

Nine studies met the inclusion criteria: three compared supervision with no supervision, five compared enhanced supervision with routine supervision, and one study compared less intensive supervision with routine supervision. Most outcomes were scores relating to providers' practice, knowledge and provider or user satisfaction. The majority of the outcomes were measured within nine months after the interventions were introduced. In two studies comparing supervision with no supervision, small benefits on provider practice and knowledge were found. For methods of enhancing supervision, we identified five studies, and two studies of frequent supportive supervision demonstrated small benefits on workers performance. The one study examining the impact of less intensive supervision found no evidence that reducing the frequency of visits had any effect on the utilisation of services. The GRADE evidence quality for all comparisons and outcomes was "low" or "very low".

AUTHORS' CONCLUSIONS

It is uncertain whether supervision has a substantive, positive effect on the quality of primary health care in low- and middle-income countries. The long term effectiveness of supervision is unknown.

Supervision of community peer counsellors for infant feeding in South Africa: an exploratory qualitative study

BACKGROUND

Recent years have seen a re-emergence of community health worker (CHW) interventions, especially in relation to HIV care, and in increasing coverage of child health interventions. Such programmes can be particularly appealing in the face of human resource shortages and fragmented health systems. However, do we know enough about how these interventions function in order to support the investment? While research based on strong quantitative study designs such as randomised controlled trials increasingly document their impact, there has been less empirical analysis of the internal mechanisms through which CHW interventions succeed or fail. Qualitative process evaluations can help fill this gap.

METHODS

This qualitative paper reports on the experience of three CHW supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomized controlled trial of infant feeding peer counselling support.

RESULTS

Our findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors.

CONCLUSIONS

This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field. Such understanding can enhance future policy making, planning and implementation of peer community health worker programmes.

Information for disasters, information disasters, and disastrous information

Information is needed to support humanitarian responses in every phase of a disaster. Participants of a multilateral working group convened to examine how best to meet these information needs. Although information systems based on routine reporting of diseases are desirable because they have the potential to identify trends, these systems usually do not deliver on their promise due to inadequate organization and management to support them. To identify organizational and management characteristics likely to be associated with successful information systems in disaster settings, evaluations of the Integrated Disease Surveillance and Response (IDSR) programs in 12 participating countries were reviewed. Characteristics that were mentioned repeatedly in the evaluations as associated with success were grouped into nine categories: (1) human resources management and supervision; (2) political support; (3) strengthened laboratory capacity; (4) communication and feedback (through many mechanisms); (5) infrastructure and resources; (6) system design and capacity; (7) coordination and partnerships with stakeholders; (8) community input; and (9) evaluation. Selected characteristics and issues within each category are discussed. Based on the review of the IDSR evaluations and selected articles in the published literature, recommendations are provided for improving the short- and long-term organization and management of information systems in humanitarian responses associated with disasters. It is suggested that information systems that follow these recommendations are more likely to yield quality information and be sustainable even in disaster settings.

Measuring health program effectiveness in the field: an assessment tool

To assist field workers in program evaluation and to explicitly discuss program strengths and weaknesses, a practical method to estimate the effectiveness of public health interventions within the existing program capacity was developed. The method and materials were tested in seven countries (Afghanistan, Zimbabwe, Tanzania, Uganda, Guatemala, the Philippines, and Ghana). In this method, four core components are assessed using a questionnaire: (1) the efficacy of the intervention; (2) the level of existing human resources (i.e., quality of recruitment, training, and continuing education); (3) the infrastructure (i.e., supplies, salary, transportation, and supervision); and (4) the level of community support (i.e., access and demand). Using the assessment tool provided, program staff can determine if all necessary elements are in place for a successful program that can deliver the specific intervention. Based on the results of the assessment program, weaknesses can be identified, explicitly discussed, and addressed. The usefulness of this tool in humanitarian relief may be twofold: (1) to assess the design and implementation of effective programs; and (2) to highlight the inevitable need for capacity building as the disaster situation evolves.

Home-based management of fever in rural Uganda: community perceptions and provider opinions

BACKGROUND

Uganda was the first country to scale up Home Based Management of Fever/Malaria (HBM) in 2002. Under HBM pre-packaged unit doses with a combination Sulphadoxine/Pyrimethamin (SP) and Chloroquine (CQ) called "HOMAPAK" are administered to all febrile children by community selected voluntary drug distributors (DDs). In this study, community perceptions, health worker and drug provider opinions about the community based distribution of HOMAPAK and its effect on the use of other antimalarials were assessed.

METHODS

In 2004, four focus group discussions with mothers and 11 key informant interviews with drug sellers, drug distributors and health workers were conducted in Kasese district, western Uganda. This was complemented by three months of field observations.

RESULTS

Caretakers concurred that they were benefiting from the programme. However, according to the information from the DDs and health workers, many caretakers perceived HOMAPAK as a drug of lower quality only meant for first aid. Caretakers also expressed need for other drugs to treat other childhood diseases. The introduction of HOMAPAKs was said not to affect the sale of other allopathic antimalarial drugs in the community. DDs expressed concerns about lack of incentives and facilitation such as torches, gumboots and diagnostic equipment to improve their performance.

CONCLUSION

HBM is well appreciated by the community. However, more efforts are needed to improve uptake of the strategy through systematic community sensitization and community dialogue. This study highlights the potential of community based volunteers if well trained, facilitated and integrated into a functioning local health system.

Effect of multiple interventions on community health workers' adherence to clinical guidelines in Siaya district, Kenya

Evaluation of a community health worker (CHW) programme in Siaya district, Kenya, showed CHWs commonly made errors in managing childhood illness. We assessed the effect of multiple interventions on CHW healthcare practices. A sample of 192 ill-child consultations performed by 114 CHWs in a hospital outpatient department between February and March 2001 were analysed. The mean percentage of assessment, classification and treatment procedures performed correctly for each child was 79.8% (range 13.3-100%). Of the 187 children who required at least one treatment or referral to a health facility, only 38.8% were prescribed all treatments (including referral) recommended by the guidelines. Multivariate analyses found no evidence that the intervention-related factors studied (refresher training, supervision, involvement of community women in the CHW selection process, adequacy of medicine supplies, and use of a guideline flipchart during consultations) were significantly associated with overall or treatment-specific guideline adherence. A multivariate linear regression analysis revealed that several non-intervention-related factors, such as patient characteristics, were significantly associated with overall guideline adherence. Given that our study was cross-sectional and our measurement of exposure to several interventions was based on CHW recall, the estimated effects of the interventions should be interpreted with caution. Despite these limitations, however, our results raise questions about the effectiveness, in the setting of Siaya district, of several interventions commonly used to improve the quality of care given by CHWs.

Intervention models for the management of children with signs of pneumonia or malaria by community health workers

A systematic review was conducted to categorize and describe Intervention Models involving community health workers (CHWs) that aim to improve case management of sick children at the household and community levels. The review focused on management of children with signs of malaria or pneumonia. Seven Intervention Models were identified, and classified according to: (1) the role of CHWs and families in assessment and treatment of children, (2) system of referral to the nearest health facility (verbal or facilitated), and (3) the location in the community of the drug stock. Standardization of terminology for Intervention Models using this or a similar classification could facilitate comparison and selection of models, including deciding how to modify programmes when policies change concerning first-line drugs, and setting priorities for further research. Of the seven models, that of CHW pneumonia case management (Model 6) has the strongest evidence for an impact on mortality. Pneumonia case management by CHWs is a child health intervention that warrants considerably more attention, particularly in Africa and South Asia.

Rural health around the world: challenges and solutions

Despite the huge differences between developing and developed countries, access is the major issue in rural health around the world. Even in the countries where the majority of the population lives in rural areas, the resources are concentrated in the cities. All countries have difficulties with transport and communication, and they all face the challenge of shortages of doctors and other health professionals in rural and remote areas. Many rural people are caught in the poverty- ill health-low productivity downward spiral, particularly in developing countries. Since 1992, WONCA, the World Organization of Family Doctors, has developed a specific focus on rural health through the WONCA Working Party on Rural Practice. This Working Party has drawn national and international attention to major rural health issues through World Rural Health Conferences and WONCA Rural Policies. The World Health Organization (WHO) has broadened its focus beyond public health to partnership with family practice, initially through a landmark WHO-WONCA Invitational Conference in Canada. From this has developed the Memorandum of Agreement between WONCA and WHO which emphasizes the important role of family practitioners in primary health care and also includes the Rural Health Initiative. In April 2002, WHO and WONCA held a major WHO-WONCA Invitational Conference on Rural Health. This conference addressed the immense challenges for improving the health of people of rural and remote areas of the world and initiated a specific action plan: The Global Initiative on Rural Health. The "Health for All" vision for rural people is more likely to be achieved through joint concerted efforts of international and national bodies working together with doctors, nurses and other health workers in rural areas around the world.

Avaliação da aplicação da estratégia da Atenção Integrada às Doenças Prevalentes da Infância (AIDPI) por Agentes Comunitários de Saúde

OBJETIVOS: avaliar a utilização da estratégia da Atenção Integrada às Doenças Prevalentes da Infância por Agentes Comunitários de Saúde. MÉTODOS: estudo do tipo avaliativo realizado nas cidades de Recife e Olinda, Nordeste do Brasil. Foram aplicados 195 questionários estruturados durante as visitas domiciliares realizadas por 106 agentes comunitários de saúde às crianças menores de cinco anos, no período de outubro a novembro de 2002. RESULTADOS: observou-se que 91,7% dos menores de dois meses foram avaliados corretamente quanto aos sinais de perigo e 83,3% quanto aos sinais de alerta. A avaliação das seções sobre "alimentação", "crescimento" e "vacina" demonstrou que o método foi bem aplicado em 96,9%, 99% e 99% dos casos, respectivamente. Em 73,1% das visitas às crianças na faixa etária entre dois meses e cinco anos, os agentes de saúde seguiram corretamente a padronização para verificação dos sinais de perigo e em 80,8% para os sinais de alerta. CONCLUSÕES: verificou-se que os agentes comunitários foram capazes de apreender o conteúdo e aplicar corretamente a estratégia. O "Manual de condutas" demonstrou ser um adequado instrumento à correta abordagem dos problemas de saúde dos menores de cinco anos na comunidade.

A literature review of the problems of delayed presentation for treatment and non-completion of treatment for tuberculosis in less developed countries and ways of addressing these problems using particular implementations of the DOTS strategy

Tuberculosis is the cause of a large burden of disease in less developed countries. With the development of drug resistance and the co-epidemic of HIV, tuberculosis has already started to make a comeback in wealthier countries. The WHO's solution to this global tuberculosis epidemic is the DOTS strategy, the implementation of which presents many problems. The two issues most common to the majority of locations are delay in presentation for treatment and non-completion of treatment. This review looks at the reasons for these problems in the less developed world, and addresses some solutions. The main reasons for delayed presentation are: a lack of understanding about TB; the stigma associated with the disease; the inaccessibility of treatment; and a preference for private practitioners. The main reasons for non-completion of treatment are: the stigma of the disease; a lack of information; dissatisfaction with the treatment and its delivery; and inaccessibility of treatment. Successful implementations of the DOTS strategy need to address all these issues. There is little evidence that DOT enhances treatment completion unless combined with other strategies. Community-based, patient-orientated DOTS appears to be an appropriate way of addressing many of these issues. The involvement of volunteers in community-based strategies is common, but needs more research in order for this strategy to realise its full potential.

Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study

BACKGROUND

Self-medication and non-doctor prescribing of drugs is common in developing countries. Complementary and alternative medications, especially herbs, are also commonly used. There are few studies on the use of these medications in Pokhara Valley, Western Nepal.

METHODS

Previously briefed seventh semester medical students, using a semi-structured questionnaire, carried out the study on 142 respondents. Demographic information and information on drugs used for self-medication or prescribed by a non-allopathic doctor were collected.

RESULTS

Seventy-six respondents (54%) were aged between 20 to 39 years. The majority of the respondents (72 %) stayed within 30 minutes walking distance of a health post/medical store. 59% of these respondents had taken some form of self-medication in the 6-month period preceding the study. The common reasons given for self-medication were mild illness, previous experience of treating a similar illness, and non-availability of health personnel. 70% of respondents were prescribed allopathic drugs by a non-allopathic doctor. The compounder and health assistant were common sources of medicines. Paracetamol and antimicrobials were the drugs most commonly prescribed. A significantly higher proportion of young (<40 years) male respondents had used self-medication than other groups.

CONCLUSIONS

Self-medication and non-doctor prescribing are common in the Pokhara valley. In addition to allopathic drugs, herbal remedies were also commonly used for self-medication. Drugs, especially antimicrobials, were not taken for the proper duration. Education to help patients decide on the appropriateness of self-medication is required.

Management of childhood illness at health facilities in Benin: problems and their causes

OBJECTIVES

To prepare for the implementation of Integrated Management of Childhood Illness (IMCI) in Benin, we studied the management of ill children younger than 5 years at outpatient health facilities.

METHODS

We observed a representative sample of consultations; after each consultation, we interviewed caregivers and reexamined children. Health workers' performance was evaluated against IMCI guidelines. To identify determinants of performance, statistical modeling was performed and 6 focus groups with health workers were conducted to solicit their opinions.

RESULTS

Altogether, 584 children were enrolled and 101 health workers were observed; 130 health workers participated in focus group discussions. Many serious deficiencies were found: incomplete assessment of children's signs and symptoms, incorrect diagnosis and treatment of potentially life-threatening illnesses, inappropriate prescription of dangerous sedatives, missed opportunities to vaccinate, and failure to refer severely ill children for hospitalization. Quantitative and qualitative analyses showed various health facility-, health worker-, caregiver-, and child-related factors as possible determinants of health worker performance.

CONCLUSIONS

Action is urgently needed. Our results suggest that to improve health care delivery, interventions should target both the health system and the community level.

Community health worker performance in the management of multiple childhood illnesses: Siaya District, Kenya, 1997-2001

OBJECTIVES

To characterize community health worker (CHW) performance using an algorithm for managing common childhood illnesses in Siaya District, Kenya, we conducted CHW evaluations in 1998, 1999, and 2001.

METHODS

Randomly selected CHWs were observed managing sick outpatient and inpatient children at a hospital, and their management was compared with that of an expert clinician who used the algorithm.

RESULTS

One hundred, 108, and 114 CHWs participated in the evaluations in 1998, 1999, and 2001, respectively. The proportions of children treated "adequately" (with an antibiotic, antimalarial, oral rehydration solution, or referral, depending on the child's disease classifications) were 57.8%, 35.5%, and 38.9%, respectively, for children with a severe classification and 27.7%, 77.3%, and 74.3%, respectively, for children with a moderate (but not severe) classification. CHWs adequately treated 90.5% of malaria cases (the most commonly encountered classification). CHWs often made mistakes assessing symptoms, classifying illnesses, and prescribing correct doses of medications.

CONCLUSIONS

Deficiencies were found in the management of sick children by CHWs, although care was not consistently poor. Key reasons for the deficiencies appear to be guideline complexity and inadequate clinical supervision; other possible causes are discussed.