1
|
Kyomuhangi T, Manalili K, Kabakyenga J, Turyakira E, Matovelo D, Khan S, Kyokushaba C, MacIntosh H, Brenner JL. Health system strengthening using a Maximizing Engagement for Readiness and Impact (MERI) Approach: A community case study. Front Public Health 2022; 10:952213. [PMID: 36504976 PMCID: PMC9727261 DOI: 10.3389/fpubh.2022.952213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Health system strengthening initiatives in low and middle-income countries are commonly hampered by limited implementation readiness. The Maximizing Engagement for Readiness and Impact (MERI) Approach uses a system "readiness" theory of change to address implementation obstacles. MERI is documented based on field experiences, incorporating best practices, and lessons learned from two decades of maternal, newborn, and child health (MNCH) programming in East Africa. Context The MERI Approach is informed by four sequential and progressively larger MNCH interventions in Uganda and Tanzania. Intervention evaluations incorporating qualitative and quantitative data sources assessed health and process outcomes. Implementer, technical leader, stakeholder, and policymaker reflections on sequential experiences have enabled MERI Approach adaptation and documentation, using an implementation lens and an implementation science readiness theory of change. Key programmatic elements The MERI Approach comprises three core components. MERI Change Strategies (meetings, equipping, training, mentoring) describe key activity types that build general and intervention-specific capacity to maximize and sustain intervention effectiveness. The SOPETAR Process Model (Scan, Orient, Plan, Equip, Train, Act, Reflect) is a series of purposeful steps that, in sequence, drive each implementation level (district, health facility, community). A MERI Motivational Framework identifies foundational factors (self-reliance, collective-action, embeddedness, comprehensiveness, transparency) that motivate participants and enhance intervention adoption. Components aim to enhance implementer and system readiness while engaging broad stakeholders in capacity building activities toward health outcome goals. Activities align with government policy and programming and are embedded within existing district, health facility, and community structures. Discussion This case study demonstrates feasibility of the MERI Approach to support district wide MNCH programming in two low-income countries, supportive of health outcome and health system improvements. The MERI Approach has potential to engage districts, health facilities, and communities toward sustainable health outcomes, addressing intervention implementation gaps for current and emerging health needs within and beyond East Africa.
Collapse
Affiliation(s)
- Teddy Kyomuhangi
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda,*Correspondence: Teddy Kyomuhangi
| | - Kimberly Manalili
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda,Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Eleanor Turyakira
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda,Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dismas Matovelo
- Department of Obstetrics and Gynecology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Sobia Khan
- The Center for Implementation, Toronto, ON, Canada
| | - Clare Kyokushaba
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Heather MacIntosh
- Indigenous, Local and Global Health Office, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer L. Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada,Indigenous, Local and Global Health Office, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
2
|
Ndejjo R, Musinguzi G, Nuwaha F, Wanyenze RK, Bastiaens H. Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study. BMC Public Health 2020; 20:75. [PMID: 31948423 PMCID: PMC6966788 DOI: 10.1186/s12889-020-8188-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are on the rise in many low-and middle-income countries where 80% of related deaths are registered. Community CVD prevention programmes utilizing self-care approaches have shown promise in contributing to population level reduction of risk factors. However, the acceptability of these programmes, which affects their uptake and effectiveness, is unknown including in the sub-Saharan Africa context. This study used the Theoretical Framework of Acceptability to explore the prospective acceptability of a community CVD prevention programme in Mukono and Buikwe districts in Uganda. METHODS This qualitative descriptive study was conducted in March 2019 among community health workers (CHWs), who would implement the intervention and community members, the intervention recipients, using eight focus group discussions. All discussions were audio-recorded, transcribed verbatim and analysed thematically guided by the theoretical framework. RESULTS CHWs and community members reported high eagerness to participate in the programme. Whereas CHWs had implemented similar community programmes and cited health promotion as their role, community members looked forward to health services being brought nearer to them. Although the intervention was preventive in nature, CHWs and community members expressed high interest in treatments for risk factors and were skeptical about the health system capacity to deliver them. CHWs anticipated barriers in mobilising communities who they said sometimes may not be cooperative while community members were concerned about failing to access treatment and support services after screening for risk factors. The major cost to CHWs and community members for engaging in the intervention was time that they would have dedicated to income generating activities and social events though CHWs also had the extra burden of being exemplary. CHWs were confident in their ability to deliver the intervention as prescribed if well trained, supported and supervised, and community members felt that if provided sufficient information and supported by CHWs, they could change their behaviours. CONCLUSIONS The community CVD prevention programme was highly acceptable among CHWs and community members in Mukono and Buikwe districts of Uganda amidst a few burdens and opportunity costs. Suggestions made by study participants to improve programme effectiveness informed programme design and implementation for impact.
Collapse
Affiliation(s)
- Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Primary and Interdisciplinary care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Geofrey Musinguzi
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Primary and Interdisciplinary care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Fred Nuwaha
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Hilde Bastiaens
- Department of Primary and Interdisciplinary care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
3
|
Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O’Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018. [DOI: 10.7189/jogh.06.0207028.010401] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
4
|
Winters N, O'Donovan J, Geniets A. A new era for community health in countries of low and middle income? LANCET GLOBAL HEALTH 2018; 6:e489-e490. [PMID: 29653617 DOI: 10.1016/s2214-109x(18)30072-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 02/13/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Niall Winters
- University of Oxford, Department of Education, Learning and New Technologies Research Group, Oxford OX2 6PY, UK.
| | - James O'Donovan
- University of Oxford, Department of Education, Learning and New Technologies Research Group, Oxford OX2 6PY, UK
| | - Anne Geniets
- University of Oxford, Department of Education, Learning and New Technologies Research Group, Oxford OX2 6PY, UK
| |
Collapse
|
5
|
Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O'Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018; 8:010401. [PMID: 29497500 PMCID: PMC5823030 DOI: 10.7189/jogh.08.010401] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background The continued success of community case management (CCM) programs in low-resource settings depends on the ability of these programs to retain the community health workers (CHWs), many of whom are volunteers, and maintain their high-quality performance. This study aims to identify factors related to the motivation and satisfaction of CHWs working in a malaria CCM program in two sub-counties in Western Kenya. Methods We interviewed 70 CHWs who were trained to administer malaria rapid diagnostic tests as part of a broader study evaluating a malaria CCM program. We identified factors related to CHWs' motivation and their satisfaction with participation in the program, as well as the feasibility of program scale-up. We used principal components analysis to develop an overall CHW satisfaction score and assessed associations between this score and individual CHW characteristics as well as their experiences in the program. Results The majority of CHWs reported that they were motivated to perform their role in this malaria CCM program by a personal desire to help their community (69%). The most common challenge CHWs reported was a lack of community understanding about malaria diagnostic testing and CHWs' role in the program (39%). Most CHWs (89%) reported that their involvement in the diagnostic testing intervention had either a neutral or a net positive effect on their other CHW activities, including improving skills applicable to other tasks. CHWs who said they strongly agreed with the statement that their work with the malaria program was appreciated by the community had a 0.76 standard deviation (SD) increase in their overall satisfaction score (95% confidence interval CI = 0.10-1.24, P = 0.03). Almost all CHWs (99%) strongly agreed that they wanted to continue their role in the malaria program. Conclusions Overall, CHWs reported high satisfaction with their role in community-based malaria diagnosis, though they faced challenges primarily related to community understanding and appreciation of the services they provided. CHWs' perceptions that the malaria program generally did not interfere with their other activities is encouraging for the sustainability and scale-up of similar CHW programs.
Collapse
Affiliation(s)
| | - Adriane Lesser
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Diana Menya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joy N Baumgartner
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Indrani Saran
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Wendy Prudhomme-O'Meara
- Duke University, Durham, North Carolina, USA.,Duke University, Duke Global Health Institute, Durham, North Carolina, USA.,Moi University, School of Public Health, Eldoret, Kenya
| |
Collapse
|
6
|
Ludwick T, Turyakira E, Kyomuhangi T, Manalili K, Robinson S, Brenner JL. Supportive supervision and constructive relationships with healthcare workers support CHW performance: Use of a qualitative framework to evaluate CHW programming in Uganda. HUMAN RESOURCES FOR HEALTH 2018; 16:11. [PMID: 29439743 PMCID: PMC5812047 DOI: 10.1186/s12960-018-0272-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/29/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND While evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries, key implementation gaps remain. Tools for assessing CHW performance and evidence on what programmatic components affect performance are lacking. This study developed and tested a qualitative evaluative framework and tool to assess CHW team performance in a district program in rural Uganda. METHODS A new assessment framework was developed to collect and analyze qualitative evidence based on CHW perspectives on seven program components associated with effectiveness (selection; training; community embeddedness; peer support; supportive supervision; relationship with other healthcare workers; retention and incentive structures). Focus groups were conducted with four high/medium-performing CHW teams and four low-performing CHW teams selected through random, stratified sampling. Content analysis involved organizing focus group transcripts according to the seven program effectiveness components, and assigning scores to each component per focus group. RESULTS Four components, 'supportive supervision', 'good relationships with other healthcare workers', 'peer support', and 'retention and incentive structures' received the lowest overall scores. Variances in scores between 'high'/'medium'- and 'low'-performing CHW teams were largest for 'supportive supervision' and 'good relationships with other healthcare workers.' Our analysis suggests that in the Bushenyi intervention context, CHW team performance is highly correlated with the quality of supervision and relationships with other healthcare workers. CHWs identified key performance-related issues of absentee supervisors, referral system challenges, and lack of engagement/respect by health workers. Other less-correlated program components warrant further study and may have been impacted by relatively consistent program implementation within our limited study area. CONCLUSIONS Applying process-oriented measurement tools are needed to better understand CHW performance-related factors and build a supportive environment for CHW program effectiveness and sustainability. Findings from a qualitative, multi-component tool developed and applied in this study suggest that factors related to (1) supportive supervision and (2) relationships with other healthcare workers may be strongly associated with variances in performance outcomes within a program. Careful consideration of supervisory structure and health worker orientation during program implementation are among strategies proposed to increase CHW performance.
Collapse
Affiliation(s)
- Teralynn Ludwick
- School of Public Health, University of Alberta, 116 St & 85 Ave, Edmonton, AB T6G 2R3 Canada
| | - Eleanor Turyakira
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, P.O BOX 1410 Mbarara, Uganda
| | - Teddy Kyomuhangi
- Maternal, Newborn, and Child Health Institute, Mbarara University of Science and Technology, P.O BOX 1410 Mbarara, Uganda
| | - Kimberly Manalili
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4 Canada
| | - Sheila Robinson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4 Canada
| | - Jennifer L. Brenner
- Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4 Canada
| |
Collapse
|
7
|
Kuule Y, Dobson AE, Woldeyohannes D, Zolfo M, Najjemba R, Edwin BMR, Haven N, Verdonck K, Owiti P, Wilkinson E. Community Health Volunteers in Primary Healthcare in Rural Uganda: Factors Influencing Performance. Front Public Health 2017; 5:62. [PMID: 28424765 PMCID: PMC5372810 DOI: 10.3389/fpubh.2017.00062] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/14/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Community health volunteers (CHVs) play an integral role in primary healthcare. Several countries rely on CHV programs as a major element in improving access to care and attaining universal health coverage. However, their performance has been heterogeneous and at times context-specific, and influenced by multiple factors. We describe the socio-demographic and workplace characteristics affecting CHVs’ performance in a public health program in rural western Uganda. Methods This was a cross-sectional study based on routine program data of CHVs serving the catchment of Bwindi Community Hospital, Kanungu District, South Western Uganda, in 2014 and 2015. Information was collected on individual socio-demographic and workplace characteristics of the CHVs. To assess their work output, we defined study-specific targets in terms of attendance at monthly CHVs’ meetings with community health nurses, households followed-up and reported, children screened for malnutrition, immunization coverage, and health facility deliveries. Frequencies and proportions are reported for characteristics and outputs and odds ratios for study-specific factors associated with overall performance. Results Of the 508 CHVs, 65% were women, 48% were aged 35 years and below, and 37% took care of more than the recommended 20–30 households. Seventy-eight percent of the CHVs had ≥80% of pregnant women under their care delivering in health units, 71% had ≥95% of the children on schedule for routine immunization, while 27% screened ≥75% of the children under 5 years for malnutrition. More refresher trainings was associated with better overall performance [adjusted odds ratio (aOR): 12.2, 95% confidence interval (CI): 1.6–93.6, P = 0.02] while overseeing more than the recommended 20–30 households reduced overall performance (aOR: 0.6, 95% CI: 0.4–0.9, P = 0.02). Conclusion Being in-charge of more than the recommended households was associated with reduced performance of CHVs, while more refresher trainings were associated with improved performance. If the CHVs are to remain a strategic pillar in universal health coverage, it is imperative to address those factors known to impact on their performance.
Collapse
Affiliation(s)
- Yusufu Kuule
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Andrew Eric Dobson
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | | | - Maria Zolfo
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Nahabwe Haven
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | | | - Philip Owiti
- The International Union Against Tuberculosis and Lung Disease, Paris, France.,Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Ewan Wilkinson
- Institute of Medicine, University of Chester, Chester, UK
| |
Collapse
|
8
|
Corluka A, Cohen M, Lanktree E, Larocque R. Uptake and impact of research for evidence-based practice: lessons from the Africa Health Systems Initiative Support to African Research Partnerships. BMC Health Serv Res 2014; 14 Suppl 1:I1. [PMID: 25078782 PMCID: PMC4108907 DOI: 10.1186/1472-6963-14-s1-i1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|