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Aron MB, Ndambo MK, Munyaneza F, Mulwafu M, Makungwa H, Nhlema B, Connolly E. A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi. HUMAN RESOURCES FOR HEALTH 2023; 21:51. [PMID: 37365561 DOI: 10.1186/s12960-023-00839-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi. METHODS We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks. RESULTS We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05). CONCLUSION This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.
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Affiliation(s)
- Moses Banda Aron
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi.
| | | | | | - Manuel Mulwafu
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | - Henry Makungwa
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | | | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, United States of America
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, United States of America
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Shelley KD, Frumence G, Mpembeni R, Mwinnyaa G, Joachim J, Kisusi HK, Killewo J, Baqui AH, Peters DH, George AS. "Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania. Int J Health Policy Manag 2019; 8:538-549. [PMID: 31657176 PMCID: PMC6815988 DOI: 10.15171/ijhpm.2019.38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 05/20/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model. Methods: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings. Results: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.
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Affiliation(s)
- Katharine D Shelley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - George Mwinnyaa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juliana Joachim
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Asha S George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Ajayi IO, Nsungwa-Sabiiti J, Siribié M, Falade CO, Sermé L, Balyeku A, Afonne C, Sanou AK, Kabarungi V, Oshiname FO, Gansane Z, Kyaligonza J, Jegede AS, Tiono AB, Sirima SB, Diarra A, Yusuf OB, Fouque F, Castellani J, Petzold M, Singlovic J, Gomes M. Feasibility of Malaria Diagnosis and Management in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study. Clin Infect Dis 2018; 63:S245-S255. [PMID: 27941101 PMCID: PMC5146694 DOI: 10.1093/cid/ciw622] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background. Malaria-endemic countries are encouraged to increase, expedite, and standardize care based on parasite diagnosis and treat confirmed malaria using oral artemisinin-based combination therapy (ACT) or rectal artesunate plus referral when patients are unable to take oral medication. Methods. In 172 villages in 3 African countries, trained community health workers (CHWs) assessed and diagnosed children aged between 6 months and 6 years using rapid histidine-rich protein 2 (HRP2)–based diagnostic tests (RDTs). Patients coming for care who could take oral medication were treated with ACTs, and those who could not were treated with rectal artesunate and referred to hospital. The full combined intervention package lasted 12 months. Changes in access and speed of care and clinical course were determined through 1746 random household interviews before and 3199 during the intervention. Results. A total of 15 932 children were assessed: 6394 in Burkina Faso, 2148 in Nigeria, and 7390 in Uganda. Most children assessed (97.3% [15 495/15 932]) were febrile and most febrile cases (82.1% [12 725/15 495]) tested were RDT positive. Almost half of afebrile episodes (47.6% [204/429]) were RDT positive. Children eligible for rectal artesunate contributed 1.1% of episodes. The odds of using CHWs as the first point of care doubled (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.9–2.4; P < .0001). RDT use changed from 3.2% to 72.9% (OR, 80.8; 95% CI, 51.2–127.3; P < .0001). The mean duration of uncomplicated episodes reduced from 3.69 ± 2.06 days to 3.47 ± 1.61 days, Degrees of freedom (df) = 2960, Student's t (t) = 3.2 (P = .0014), and mean duration of severe episodes reduced from 4.24 ± 2.26 days to 3.7 ± 1.57 days, df = 749, t = 3.8, P = .0001. There was a reduction in children with danger signs from 24.7% before to 18.1% during the intervention (OR, 0.68; 95% CI, .59–.78; P < .0001). Conclusions. Provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases. This approach, recommended by the World Health Organization, improves malaria case management. Clinical Trials Registration. ISRCTN13858170.
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Affiliation(s)
| | | | | | | | - Luc Sermé
- Child Health Division, Ministry of Health, Kampala, Uganda
| | - Andrew Balyeku
- Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso
| | - Chinenye Afonne
- Epidemiology and Biostatistics Research Unit, Institute of Advance Medical Research and Training (IMARAT)
| | | | | | - Frederick O Oshiname
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine
| | | | | | - Ayodele S Jegede
- Department of Sociology, Faculty of Social Sciences, IMARAT, University of Ibadan, Nigeria
| | - Alfred B Tiono
- Child Health Division, Ministry of Health, Kampala, Uganda
| | | | - Amidou Diarra
- Child Health Division, Ministry of Health, Kampala, Uganda
| | | | - Florence Fouque
- UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Joëlle Castellani
- Department of Health Services Research, School for Public Health and Primary Care, Maastricht University, The Netherlands
| | - Max Petzold
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Jan Singlovic
- UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Melba Gomes
- UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
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Warsame M, Gyapong M, Mpeka B, Rodrigues A, Singlovic J, Babiker A, Mworozi E, Agyepong I, Ansah E, Azairwe R, Biai S, Binka F, Folb P, Gyapong J, Kimbute O, Machinda Z, Kitua A, Lutalo T, Majaha M, Mamadu J, Mrango Z, Petzold M, Rujumba J, Ribeiro I, Gomes M. Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial. Clin Infect Dis 2018; 63:S312-S321. [PMID: 27941110 PMCID: PMC5146703 DOI: 10.1093/cid/ciw631] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background. If malaria patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate prior to hospital referral can prevent death and disability. The goal is to reduce death from malaria by having rectal artesunate treatment available and used. How best to do this remains unknown. Methods. Villages remote from a health facility were randomized to different community-based treatment providers trained to provide rectal artesunate in Ghana, Guinea-Bissau, Tanzania, and Uganda. Prereferral rectal artesunate treatment was provided in 272 villages: 109 through community-based health workers (CHWs), 112 via trained mothers (MUMs), 25 via trained traditional healers (THs), and 26 through trained community-chosen personnel (COMs); episodes eligible for rectal artesunate were established through regular household surveys of febrile illnesses recording symptoms eligible for prereferral treatment. Differences in treatment coverage with rectal artesunate in children aged <5 years in MUM vs CHW (standard-of-care) villages were assessed using the odds ratio (OR); the predictive probability of treatment was derived from a logistic regression analysis, adjusting for heterogeneity between clusters (villages) using random effects. Results. Over 19 months, 54 013 children had 102 504 febrile episodes, of which 32% (31 817 episodes) had symptoms eligible for prereferral therapy; 14% (4460) children received treatment. Episodes with altered consciousness, coma, or convulsions constituted 36.6% of all episodes in treated children. The overall OR of treatment between MUM vs CHW villages, adjusting for country, was 1.84 (95% confidence interval [CI], 1.20–2.83; P = .005). Adjusting for heterogeneity, this translated into a 1.67 higher average probability of a child being treated in MUM vs CHW villages. Referral compliance was 81% and significantly higher with CHWs vs MUMs: 87% vs 82% (risk ratio [RR], 1.1 [95% CI, 1.0–1.1]; P < .0001). There were more deaths in the TH cluster than elsewhere (RR, 2.7 [95% CI, 1.4–5.6]; P = .0040). Conclusions. Prereferral episodes were almost one-third of all febrile episodes. More than one-third of patients treated had convulsions, altered consciousness, or coma. Mothers were effective in treating patients, and achieved higher coverage than other providers. Treatment access was low. Clinical Trials Registration. ISRCTN58046240.
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Affiliation(s)
- Marian Warsame
- Division of International Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Jan Singlovic
- Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Abdel Babiker
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | | | | | - Evelyn Ansah
- Dangme West District Health Directorate, Dodowa, Ghana
| | - Robert Azairwe
- National Malaria Control Programme, World Health Organization Uganda Country Office, Kampala
| | - Sidu Biai
- Projecto de Saude de Bandim, Guinea-Bissau
| | - Fred Binka
- University of Health and Allied Sciences, Ho, Ghana
| | - Peter Folb
- Medical Research Council, Tygerberg, South Africa
| | | | - Omari Kimbute
- National Institute for Medical Research, Dar-es-Salaam
| | | | - Andrew Kitua
- Preparedness and Response Project, Lugogo House, Kampala, Uganda
| | - Tom Lutalo
- Rakai Health Sciences Program, Rakai Project Centre, Entebbe, Uganda
| | - Melkzedik Majaha
- National Institute for Medical Research, Gonja Field Station, Tanzania
| | - Jao Mamadu
- Projecto de Saude de Bandim, Guinea-Bissau
| | - Zakayo Mrango
- National Institute for Medical Research, Dar-es-Salaam
| | - Max Petzold
- Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Joseph Rujumba
- College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Melba Gomes
- Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
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Sanou AK, Jegede AS, Nsungwa-Sabiiti J, Siribié M, Ajayi IO, Turinde A, Oshiname FO, Sermé L, Kabarungi V, Falade CO, Kyaligonza J, Afonne C, Balyeku A, Castellani J, Gomes M. Motivation of Community Health Workers in Diagnosing, Treating, and Referring Sick Young Children in a Multicountry Study. Clin Infect Dis 2018; 63:S270-S275. [PMID: 27941104 PMCID: PMC5146697 DOI: 10.1093/cid/ciw625] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background. Community health workers (CHWs) are an important element of care provision for a wide range of conditions, but their turnover rate is high. Many studies have been conducted on health workers’ motivation, focusing on formal sector staff but not CHWs. Although CHWs are easy to recruit, motivating and retaining them for service delivery is difficult. This article investigates factors influencing CHW motivation and retention in health service delivery. Methods. Quantitative and qualitative data were collected to identify the key factors favoring motivation and retention of CHWs as well as those deterring them. We interviewed 47, 25, and 134 CHWs in Burkina Faso, Nigeria, and Uganda, respectively, using a structured questionnaire. Focus group discussions (FGDs) were also conducted with CHWs, community participants, and facility health workers. Results. Except for Burkina Faso, most CHWs were female. Average age was between 38 and 41 years, and most came from agricultural communities. The majority (52%–80%) judged they had a high to very high level of satisfaction, but most CHWs (approximately 75%) in Burkina Faso and Uganda indicated that they would be prepared to leave the job, citing income as a major reason. Community recognition and opportunities for training and supervision were major incentives in all countries, but the volume of unremunerated work, at a time when both malaria-positive cases and farming needs were at their peak, was challenging. Conclusions. Most CHWs understood the volunteer nature of their position but desired community recognition and modest financial remuneration. Clinical Trials Registration. ISRCTN13858170.
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Affiliation(s)
- Armande K Sanou
- Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso
| | | | | | | | | | - Asaf Turinde
- Child Health Division, Ministry of Health, Kampala, Uganda
| | | | - Luc Sermé
- Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso
| | | | | | | | - Chinenye Afonne
- Epidemiology and Biostatistics Research Unit, Institute of Advanced Medical Research and Training, College of Medicine, University of Ibadan, Nigeria
| | - Andrew Balyeku
- Child Health Division, Ministry of Health, Kampala, Uganda
| | - Joëlle Castellani
- Department of Health Services Research, School for Public Health and Primary Care, Maastricht University, The Netherlands
| | - Melba Gomes
- UNICEF/UNDP/World Bank/WHO/Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
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Gunda R, Shamu S, Chimbari MJ, Mukaratirwa S. Economic burden of malaria on rural households in Gwanda district, Zimbabwe. Afr J Prim Health Care Fam Med 2017; 9:e1-e6. [PMID: 28893077 PMCID: PMC5594239 DOI: 10.4102/phcfm.v9i1.1317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 05/12/2017] [Accepted: 05/15/2017] [Indexed: 11/23/2022] Open
Abstract
Background Malaria is a serious public health problem in sub-Saharan Africa and is a leading cause of morbidity and mortality. Aim To estimate the economic burden of malaria in rural households. Setting The study was conducted in Gwanda district of Matabeleland South in Zimbabwe. A total of five malarious wards and all their households were selected for the study frame, out of which 80 households were chosen using clinic records. Methods A retrospective analysis of secondary data and a cross-sectional household survey were conducted to estimate the household economic burden of malaria. Eighty households from five rural wards were identified from the health facility malaria registers and followed up. A household was eligible for inclusion if there had been at least one reported malaria case during the period of 2013−2015. Interviewer administered questionnaires were used to collect household data on economic costs of malaria. Results Our findings showed that households spent an average of $3.22 and $56.60 for managing an uncomplicated and a complicated malaria episode respectively. A household lost an average of eight productive working days per each malaria episode resulting in an average loss of 24% of the monthly household income. An estimated 35%, mostly poorer households suffered catastrophic health expenditures. Conclusion Malaria imposes significant economic burdens particularly on the poorer and vulnerable households. Although there are no user fees at rural clinics, households incur other costs to manage a malaria patient. These costs are far worse for complicated cases.
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Affiliation(s)
- Resign Gunda
- School of Nursing and Public Health, University of KwaZulu-Natal.
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