1
|
Ballard M, Olaniran A, Iberico MM, Rogers A, Thapa A, Cook J, Aranda Z, French M, Olsen HE, Haughton J, Lassala D, Carpenter Westgate C, Malitoni B, Juma M, Perry HB. Labour conditions in dual-cadre community health worker programmes: a systematic review. Lancet Glob Health 2023; 11:e1598-e1608. [PMID: 37734803 DOI: 10.1016/s2214-109x(23)00357-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/23/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Health care delivered by community health workers reduces morbidity and mortality while providing a considerable return on investment. Despite growing consensus that community health workers, a predominantly female workforce, should receive a salary, many community health worker programmes take the form of dual-cadre systems, where a salaried cadre of community health workers works alongside a cadre of unsalaried community health workers. We aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre programmes. METHODS We did a systematic review of available evidence from peer-reviewed databases and grey literature from database inception to Aug 2, 2021, for studies on unsalaried community health worker cadres in dual-cadre systems. Editorials, protocols, guidelines, or conference reports were excluded in addition to studies about single-tier community health worker programmes and those reporting on only salaried cadres of community health workers in a dual-cadre system. We extracted data on remuneration, workload, task complexity, and self-reported experiences of community health workers. Three models were created: a minimum model with the shortest time and frequency per task documented in the literature, a maximum model with the longest time, and a median model. Labour exploitation was defined as being engaged in work below the country's minimum wage together with excessive work hours or complex tasks. The study was registered with PROSPERO, CRD42021271500. FINDINGS We included 117 reports from 112 studies describing community health workers in dual-cadre programmes across 19 countries. The majority of community health workers were female. 13 (59%) of 22 unsalaried community health worker cadres and one (10%) of ten salaried cadres experienced labour exploitation. Three (17%) of 18 unsalaried community health workers would need to work more than 40 h per week to fulfil their assigned responsibilities. Unsalaried community health worker cadres frequently reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload. INTERPRETATION Unsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services. FUNDING None.
Collapse
Affiliation(s)
- Madeleine Ballard
- Community Health Impact Coalition, London, UK; Department of Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | - M Matías Iberico
- Partners in Health Mexico, Ángel Albino Corzo, México; Tulane University School of Medicine, New Orleans, LA, USA
| | - Ash Rogers
- Lwala Community Alliance, Nashville, TN, USA
| | | | | | - Zeus Aranda
- Partners in Health Mexico, Ángel Albino Corzo, México; El Colegio de la Frontera Sur, San Cristóbal de las Casas, México
| | | | | | - Jessica Haughton
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | | | | |
Collapse
|
2
|
Kang J, Kang P. Relationship Building between International Healthcare Volunteers and Local Healthcare Providers in Ethiopia: Real-Life Experiences in Low-Income Country. Healthcare (Basel) 2023; 11:1969. [PMID: 37444804 DOI: 10.3390/healthcare11131969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The number of international healthcare volunteers in low-income countries that need trained human resources has been increasing. However, migrating to a foreign country requires adapting to its environment and culture. The purpose of this study was to explore the international healthcare volunteers' experiences in Ethiopia in building relationships with local healthcare providers. METHODS Six participants were enrolled in the study, and data were collected through individual in-depth interviews conducted between September and October 2018. The collected data were analyzed using Colaizzi's phenomenological method. RESULTS Ten subthemes emerged from five themes: "facing new situations", "accepting myself as an outsider in Ethiopia", "impact on the wall of prejudice", "adapting to a new culture", and "positive outlook". CONCLUSIONS This study shows that international healthcare volunteers in Ethiopia experienced challenges in building relationships with local healthcare providers due to linguistic and cultural gaps. Nevertheless, they strived to accept the culture and play their part as helpers in providing healthcare services.
Collapse
Affiliation(s)
- Jiwon Kang
- School of Nursing, University of Minnesota, Minneapolis, MN 55455, USA
| | - Purum Kang
- College of Nursing, Woosuk University, Wanju 55338, Jeollabuk-do, Republic of Korea
| |
Collapse
|
3
|
Closser S, Sultan M, Tikkanen R, Singh S, Majidulla A, Maes K, Gerber S, Rosenthal A, Palazuelos D, Tesfaye Y, Finley E, Abesha R, Keeling A, Justice J. Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies. BMJ Glob Health 2023; 8:bmjgh-2023-011749. [PMID: 37208121 DOI: 10.1136/bmjgh-2023-011749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/21/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Across a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. METHODS We are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews). RESULTS CHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes. CONCLUSION Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.
Collapse
Affiliation(s)
- Svea Closser
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marium Sultan
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Roosa Tikkanen
- Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - Shalini Singh
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arman Majidulla
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kenneth Maes
- Anthropology, Oregon State University, Corvallis, Oregon, USA
| | - Sue Gerber
- Independent Consultant, Truchas, New Mexico, USA
| | - Anat Rosenthal
- Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Southern, Israel
| | - Daniel Palazuelos
- Blavatnik Institute of Global Health and Social Medicine, Harvard University, Cambridge, Massachusetts, USA
| | | | - Erin Finley
- Psychiatry and Behavioral Sciences, UT Health San Antonio, San Antonio, Texas, USA
| | - Roza Abesha
- Independent Consultant, Gondar, Amhara, Ethiopia
| | | | - Judith Justice
- Institute for Health and Aging, University of California at San Francisco, Berkeley, California, USA
| |
Collapse
|
4
|
Gedefa AG, Bekele AA, Kitila KM, Eba LB. Barriers to birth preparedness and complication readiness among pregnant women in rural Ethiopia: using a mixed study design, 2020. BMJ Open 2023; 13:e069565. [PMID: 37185635 PMCID: PMC10151967 DOI: 10.1136/bmjopen-2022-069565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To assess birth preparedness and complication readiness (BPCR) and associated factors among pregnant women in Bachoo District, Oromia, Ethiopia. DESIGN A mixed cross-sectional study design was employed to conduct this study. SETTING A community-based cross-sectional study was done in the rural community of Bachoo District of Iluu Abbaa Boor Zone, Oromia Region, Southwest Ethiopia. PARTICIPANTS A total of 307 pregnant women participated in the quantitative study, 51 respondents were involved in the qualitative part. A simple random sampling technique was used to select the final respondents. Data were entered into EpiData V.3.1 and analysed using SPSS V.22. Binary and multivariable logistic regression analysis was done. The level of statistical significance was declared at a p<0.05. Three focus group discussions and 21 in-depth interviews were conducted, and the data were analysed using thematic analysis and triangulated to support the findings of the quantitative study. RESULT The prevalence of BPCR was 30.6%. Being governmental employee ((adjusted OR, AOR=3.22 95% CI (1.49 to 11.79)), educational status of secondary and above ((AOR=1.9 95% CI (1.15 to 3.84)), multigravidity ((AOR=5.96, 95% CI (1.18 to 3.68)), having four or above ANC visits ((AOR=4.25 CI (1.38 to 7.84)), participating in pregnant women conference ((AOR=2.11 95% CI (1.07 to 3.78)), having good knowledgeable of obstetrics danger signs ((AOR=10.4 95% CI (5.57 to 19.60)), hearing the term BPCR ((AOR=4.36, 95% CI (1.93 to 9.82)) were among factors significantly associated with BPCR. The qualitative study also showed that poor maternal knowledge on birth preparedness and obstetric danger signs, negligence and weak support systems in the community were among the main barriers. CONCLUSION AND RECOMMENDATION This study demonstrated that the practice of BPCR in the study area was very low. Therefore, healthcare providers in the study area should strengthen BPCR knowledge through educating women the community at large.
Collapse
Affiliation(s)
- Abdi Geda Gedefa
- College of Health Science, Public Health Departments, Mettu University, Mettu, Ethiopia
| | - Alazar Ayalew Bekele
- Bacho District Health Office, Iluu Abbaa Boor Zonal Health Office, Oromia state, Ethiopia
| | - Keno Melkamu Kitila
- Department of Public Health, College of Health Sciences Mettu University, Mettu, Ethiopia
| | - Lemi Bacha Eba
- Psychiatry Department, College of Health Science Mettu University, Mettu, Ethiopia
| |
Collapse
|
5
|
Birhane R, Medhin G, Demissie M, Tassew B, Gebru T, Tadesse B, Jebena MG, Teklu AM, Deyessa N. Depression and Burnout among Health Extension Workers in Ethiopia: A Cross-Sectional Study. Ethiop J Health Sci 2023; 33:63-74. [PMID: 38362477 PMCID: PMC10866296 DOI: 10.4314/ejhs.v33i1.7s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/24/2023] [Indexed: 02/17/2024] Open
Abstract
Background Depression and burnout are common among healthcare workers (HCWs) and negatively affect their well-being and the quality of the service they provide. However, the burden of depression and burnout among health extension workers (HEWs) in Ethiopia and their relationship has not been documented well.The objective of this study was to estimate the prevalence of depression and burnout among HEWs in Ethiopia and to investigate the relationship between these conditions. Materials and Methods We used a cross-sectional study design and collected data from 584 rural and 581 urban HEWs in Ethiopia, as part of the 2019 national health extension program assessment. The Patient Health Questionnaire (PHQ-9) and Burnout Self-Test were used to screen HEWs for depression and burnout, respectively. We used descriptive statistics to estimate the magnitude of depression and burnout, and logistic regression to examine their relationship. Result Based on PHQ-9 cutoff scores of 10, the prevalence of major depression was 16.5% among rural and 8.9% among urban HEWs, whereas burnout risk was 39.8% among rural and 12.6% among urban HEWs. The odds of having depression among HEWs with burnout risk was relatively higher compared to those without burnout risk [For rural HEWs, the adjusted odds ratio (AOR) is 11.88 at a 95% confidence interval (CI; 5.27, 26.80), and for urban HEWs, the AOR is 11.49 at a 95% CI (5.35, 24.63)]. Conclusion The prevalence of depression and burnout is high among HEWs in Ethiopia, with a significant rural-urban difference, and burnout is a significant predictor of depression. Mental health interventions that enable prevention, early detection, and management are needed especially for rural HEWs who are in charge of preventive health service delivery for the disadvantaged rural communities.
Collapse
Affiliation(s)
- Rahel Birhane
- CDT-Africa, College of Health Sciences, Addis Ababa University
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
- MERQ Consultancy PLC, Addis Ababa
| | - Mekdes Demissie
- CDT-Africa, College of Health Sciences, Addis Ababa University
- Centre for Innovative Drug Development and Therapeutic Studies for Africa (CDT-Africa), College of Health Science, Addis Ababa University
| | - Berhan Tassew
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teklemichael Gebru
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Biniyam Tadesse
- MERQ Consultancy PLC, Addis Ababa
- Department of Health Economics, Management and Policy, College of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Mulusew G Jebena
- Department of Epidemiology, Institute of Health, Jimma University
| | | | - Negussie Deyessa
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
6
|
Astale T, Abebe T, Mitike G. Workload and emerging challenges of community health workers in low- and middle-income countries: A mixed-methods systematic review. PLoS One 2023; 18:e0282717. [PMID: 36913362 PMCID: PMC10010520 DOI: 10.1371/journal.pone.0282717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/21/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Community health workers (CHWs) play an important role in improving access to health services to a broader population; particularly to communities living in remote areas. However, the productivity of CHWs is affected by the workload they have. We aimed to summarize and present CHWs' perceived workload in low-and middle-income countries (LMICs). METHODS We searched three electronic databases (PubMed, Scopus, and Embase). A search strategy customized for the three electronic databases was developed using the two key terms of the review (CHWs and workload). Primary studies conducted in LMICs that explicitly measured workload of CHWs and published in English were included, without date restrictions. Methodological quality of the articles was assessed by two reviewers independently using mixed-methods appraisal tool. We applied a convergent integrated approach to synthesize the data. This study is registered on PROSPERO, number CRD42021291133. RESULTS Of 632 unique records, 44 met our inclusion criteria, and 43 (20 qualitative, 13 mixed-methods, and 10 quantitative studies) passed the methodological quality assessment and were included in this review. In 97.7% (n = 42) of the articles, CHWs reported that they have a high workload. Having multiple tasks was the most commonly reported subcomponent of workload, followed by lack of transport; which was reported in 77.6% (n = 33) and 25.6% (n = 11) of the articles respectively. CONCLUSION CHWs in LMICs reported that they have a high workload; mainly related to having to manage multiple tasks and the lack of transport to access households. Program managers need to make careful consideration when additional tasks are shifted to CHWs and the practicability to be performed in the environment they work in. Further research is also required to make a comprehensive measure of the workload of CHWs in LMICs.
Collapse
Affiliation(s)
- Tigist Astale
- International Institute for Primary Health Care-Ethiopia, Addis Ababa, Ethiopia
| | - Tsegereda Abebe
- International Institute for Primary Health Care-Ethiopia, Addis Ababa, Ethiopia
| | - Getnet Mitike
- International Institute for Primary Health Care-Ethiopia, Addis Ababa, Ethiopia
| |
Collapse
|
7
|
Gebregizabher FA, Medhanyie AA, Bezabih AM, Persson LÅ, Abegaz DB. Is Women's Engagement in Women's Development Groups Associated with Enhanced Utilization of Maternal and Neonatal Health Services? A Cross-Sectional Study in Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1351. [PMID: 36674107 PMCID: PMC9858998 DOI: 10.3390/ijerph20021351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND In Ethiopia, the Women Development Group program is a community mobilization initiative aimed at enhancing Universal Health Coverage through supporting the primary healthcare services for mothers and newborns. This study aimed to assess the association between engagement in women's groups and the utilization of maternal and neonatal health services. METHOD A cluster-sampled community-based survey was conducted in Oromia, Amhara, Southern Nations, Nationalities and Peoples, and Tigray regions of Ethiopia from mid-December 2018 to mid-February 2019. Descriptive and logistic regression analyses were performed, considering the cluster character of the sample. RESULTS A total of 6296 women (13 to 49 years) from 181 clusters were interviewed. Of these, 896 women delivered in the 12 months prior to the survey. Only 79 (9%) of these women including Women Development Group leaders reported contact with Women Development Groups in the last 12 months preceding the survey. Women who had educations and greater economic status had more frequent contact with Women Development Group leaders. Women who had contact with Women Development Groups had better knowledge on pregnancy danger signs. Being a Women Development Group leader or having contact with Women Development Groups in the last 12 months were associated with antenatal care utilization (AOR 2.82, 95% CI (1.23, 6.45)) but not with the use of facility delivery and utilization of postnatal care services. CONCLUSIONS There is a need to improve the organization and management of the Women Development Group program as well as a need to strengthen the Women Development Group leaders' engagement in group activities to promote the utilization of maternal and neonatal health services.
Collapse
Affiliation(s)
- Fisseha Ashebir Gebregizabher
- Tigray Regional Health Bureau, Mekelle P.O. Box 07, Ethiopia
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Afework Mulugeta Bezabih
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle P.O. Box 1871, Ethiopia
| | - Lars Åke Persson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| | - Della Berhanu Abegaz
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Ethiopian Public Health Institute, Addis Ababa P.O. Box 1242, Ethiopia
| |
Collapse
|
8
|
Teferi HM, San Sebastian M, Baroudi M. Factors associated with home delivery preference among pregnant women in Ethiopia: a cross-sectional study. Glob Health Action 2022; 15:2080934. [PMID: 35867544 PMCID: PMC9310790 DOI: 10.1080/16549716.2022.2080934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Home delivery is associated with a high risk of maternal and neonatal mortality. The prevalence and factors associated with home delivery have been studied retrospectively among women in Ethiopia. However, no national studies have assessed pregnant women’s preferences for home delivery. Objective To assess factors associated with preferences for home delivery among pregnant women in Ethiopia. Methods We analysed a sample of 678 pregnant women derived from the 2019 performance monitoring for action cross-sectional survey. The association between pregnant women’s preferences for home delivery and several individual, household, healthcare, and community factors were explored through log-Poisson regression with robust variance. Results The weighted prevalence of pregnant women’s preferences for home delivery in Ethiopia was 33%. Pregnant women between the ages of 15–19 years (PR = 2.3; 95% CI: 1.43–4.00) had a higher preference for home delivery compared to those above 34 years. Those who had no Antenatal care (ANC) visit in the current pregnancy (PR = 1.5; 95% CI: 1.11–2.11), multipara women (PR = 1.8; 95% CI: 1.19–2.92) those who did not discuss place of delivery with their partners (PR = 1.5; 95% CI: 1.18–2.10), did not participate in a community-based program called ‘1 to 5’ network meetings (PR = 4.5; 95% CI: 1.09–18.95), and those who perceived low community support for facility delivery (PR = 2.2; 95% CI: 1.53–3.20) had a higher prevalence of home delivery preference compared to their references. Conclusions A significant proportion of pregnant women preferred home deliveries in Ethiopia. Household and community supporting factors such as not discussing place of delivery with a partner, not participating in women developmental army meetings, and perceived low community support were associated with preference for home delivery. Interventions should address these factors to increase facility deliveries in Ethiopia.
Collapse
Affiliation(s)
| | | | - Mazen Baroudi
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| |
Collapse
|
9
|
Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis. BMC Pregnancy Childbirth 2022; 22:674. [PMID: 36050632 PMCID: PMC9434878 DOI: 10.1186/s12884-022-04869-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. METHODS We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7-9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention's acceptability and feasibility, in terms of participants' views and the intervention aims. RESULTS We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members' negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. CONCLUSION Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.
Collapse
|
10
|
Jerene D, Assefa D, Tesfaye K, Bayu S, Seid S, Aberra F, Bedru A, Khan A, Creswell J. Effectiveness of women-led community interventions in improving tuberculosis preventive treatment in children: results from a comparative, before-after study in Ethiopia. BMJ Open 2022; 12:e062298. [PMID: 35863840 PMCID: PMC9310159 DOI: 10.1136/bmjopen-2022-062298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Our objective was to evaluate the impact of a service delivery model led by membership-based associations called Iddirs formed by women on tuberculosis preventive treatment (TPT) initiation and completion rates among children. DESIGN Comparative, before-and-after study design. SETTING Three intervention and two control districts in Ethiopia. PARTICIPANTS Children who had a history of close contact with adults with infectious forms of tuberculosis (TB). Child contacts in whom active TB and contraindications to TPT regimens were excluded were considered eligible for TPT. INTERVENTIONS Between July 2020 and June 2021, trained women Iddir members visited households of index TB patients, screened child household contacts for TB, provided education and information on the benefits of TPT, linked them to the nearby health centre and followed them at home for TPT adherence and side effects. Two control zones received the standard of care, which comprised of facility-based provision of TPT to children. We analysed quarterly TPT data for treatment initiation and completion and compared intervention and control zones before and after the interventions and tested for statistical significance using Poisson regression. PRIMARY AND SECONDARY OUTCOME MEASURES There were two primary outcome measures: proportion of eligible children initiated TPT and proportion completed treatment out of those eligible. RESULTS TPT initiation rate among eligible under-15-year-old children (U15C) increased from 28.7% to 63.5% in the intervention zones, while it increased from 34.6% to 43.2% in the control zones, and the difference was statistically significant (p<0.001). TPT initiation rate for U5C increased from 13% (17 out of 131) to 93% (937 out of 1010). Of the U5C initiated, 99% completed treatment; two discontinued due to side effects; three parents refused to continue; and one child was lost to follow-up. CONCLUSION Women-led Iddirs contributed to significant increase in TPT initiation and completion rates. The model of TPT delivery should be scaled-up.
Collapse
Affiliation(s)
- Degu Jerene
- TB Elimination and Health Systems Innovation, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Dawit Assefa
- KNCV Tuberculosis Foundation, Ethiopia Country Office, Addis Ababa, Ethiopia
| | | | - Samuel Bayu
- KNCV Tuberculosis Foundation, Ethiopia Office, Addis Ababa, Ethiopia
| | - Samuel Seid
- KNCV Tuberculosis Foundation, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Fikirte Aberra
- Southern Nations Nationalities and Peoples' Region Health Bureau, Hawassa, Ethiopia
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Amera Khan
- Innovation & Grants, Stop TB Partnership, Geneva, Switzerland
| | - Jacob Creswell
- Innovation & Grants, Stop TB Partnership, Geneva, Switzerland
| |
Collapse
|
11
|
Freeman MC, Delea MG, Snyder JS, Garn JV, Belew M, Caruso BA, Clasen TF, Sclar GD, Tesfaye Y, Woreta M, Zewudie K, Gobezayehu AG. The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000056. [PMID: 36962125 PMCID: PMC10021625 DOI: 10.1371/journal.pgph.0000056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/07/2021] [Indexed: 04/19/2023]
Abstract
Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.
Collapse
Affiliation(s)
- Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Maryann G. Delea
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jedidiah S. Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Joshua V. Garn
- School of Community Health Sciences, University of Nevada, Reno, Nevada, United States of America
| | | | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Gloria D. Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Yihenew Tesfaye
- Department of Social Anthropology, Bahir Dar University, Bahir Dar, Ethiopia
| | - Mulat Woreta
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
| | | | - Abebe Gebremariam Gobezayehu
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
- School of Nursing, Emory University, Atlanta, Georgia, United States of America
| |
Collapse
|
12
|
Tareke KG, Solomon N, Teshome F. Barriers for the Functional Implementation of Community Health Volunteers in Health Developmental Army in Debre Libanos District, Oromia, Ethiopia: A Descriptive Qualitative Study. J Multidiscip Healthc 2022; 15:103-114. [PMID: 35046664 PMCID: PMC8760987 DOI: 10.2147/jmdh.s342711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusion
Collapse
Affiliation(s)
- Kasahun Girma Tareke
- Department of Health, Behavior and Society, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
- Correspondence: Kasahun Girma Tareke Email
| | - Nahom Solomon
- Department of Public Health, Mizan Tepi University, Mizan-Aman, Ethiopia
| | - Firanbon Teshome
- Department of Health, Behavior and Society, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| |
Collapse
|
13
|
Robbins T, Hanlon C, Kelly AH, Gidiri MF, Musiyiwa M, Silverio SA, Shennan AH, Sandall J. Pills and prayers: a comparative qualitative study of community conceptualisations of pre-eclampsia and pluralistic care in Ethiopia, Haiti and Zimbabwe. BMC Pregnancy Childbirth 2021; 21:716. [PMID: 34702209 PMCID: PMC8547033 DOI: 10.1186/s12884-021-04186-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background Pre-eclampsia is a leading cause of preventable maternal and perinatal deaths globally. While health inequities remain stark, removing financial or structural barriers to care does not necessarily improve uptake of life-saving treatment. Building on existing literature elaborating the sociocultural contexts that shape behaviours around pregnancy and childbirth can identify nuanced influences relating to pre-eclampsia care. Methods We conducted a cross-cultural comparative study exploring lived experiences and understanding of pre-eclampsia in Ethiopia, Haiti and Zimbabwe. Our primary objective was to examine what local understandings of pre-eclampsia might be shared between these three under-resourced settings despite their considerable sociocultural differences. Between August 2018 and January 2020, we conducted 89 in-depth interviews with individuals and 17 focus group discussions (n = 106). We purposively sampled perinatal women, survivors of pre-eclampsia, families of deceased women, partners, older male and female decision-makers, traditional birth attendants, religious and traditional healers, community health workers and facility-based health professionals. Template analysis was conducted to facilitate cross-country comparison drawing on Social Learning Theory and the Health Belief Model. Results Survivors of pre-eclampsia spoke of their uncertainty regarding symptoms and diagnosis. A lack of shared language challenged coherence in interpretations of illness related to pre-eclampsia. Across settings, raised blood pressure in pregnancy was often attributed to psychosocial distress and dietary factors, and eclampsia linked to spiritual manifestations. Pluralistic care was driven by attribution of causes, social norms and expectations relating to alternative care and trust in biomedicine across all three settings. Divergence across the contexts centred around nuances in religious or traditional practices relating to maternal health and pregnancy. Conclusions Engaging faith and traditional caregivers and the wider community offers opportunities to move towards coherent conceptualisations of pre-eclampsia, and hence greater access to potentially life-saving care. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04186-6.
Collapse
Affiliation(s)
- Tanya Robbins
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, and WHO Collaborating Centre for Mental Health Research and Training, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ann H Kelly
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Muchabayiwa Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Mickias Musiyiwa
- Department of History, Heritage and Knowledge Systems, Faculty of Arts and Humanities, University of Zimbabwe, Harare, Zimbabwe
| | - Sergio A Silverio
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, 10th Floor, North Wing, Westminster Bridge Road, London, SE1 7EH, UK
| |
Collapse
|
14
|
Ashebir F, Medhanyie AA, Mulugeta A, Persson LÅ, Berhanu D. Exploring women's development group leaders' support to maternal, neonatal and child health care: A qualitative study in Tigray region, Ethiopia. PLoS One 2021; 16:e0257602. [PMID: 34555089 PMCID: PMC8460027 DOI: 10.1371/journal.pone.0257602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Community health workers and volunteers are vital for the achievement of Universal Health Coverage also in low-income countries. Ethiopia introduced community volunteers called women’s development group leaders in 2011. These women have responsibilities in multiple sectors, including promoting health and healthcare seeking. Objective We aimed to explore women’s development group leaders’ and health workers’ perceptions on these volunteers’ role in maternal, neonatal and child healthcare. Methods A qualitative study was conducted with in-depth interviews and focus group discussions with women’s development group leaders, health extension workers, health center staff, and woreda and regional health extension experts. We adapted a framework of community health worker performance, and explored perceptions of the women’s development group program: inputs, processes and performance. Interviews were recorded, transcribed, and coded prior to translation and thematic analysis. Results The women’s development group leaders were committed to their health-related work. However, many were illiterate, recruited in a sub-optimal process, had weak supervision and feedback, lacked training and incentives and had weak knowledge on danger signs and care of neonates. These problems demotivated these volunteers from engaging in maternal, neonatal and child health promotion activities. Health extension workers faced difficulties in managing the numerous women’s development group leaders in the catchment area. Conclusion The women’s development group leaders showed a willingness to contribute to maternal and child healthcare but lacked support and incentives. The program requires some redesign, effective management, and should offer enhanced recruitment, training, supervision, and incentives. The program should also consider continued training to develop the leaders’ knowledge, factor contextual influences, and be open for local variations.
Collapse
Affiliation(s)
- Fisseha Ashebir
- Tigray Regional Health Bureau, Mekelle, Tigray, Ethiopia.,School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Afework Mulugeta
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| |
Collapse
|
15
|
Schaaf M, Warthin C, Freedman L, Topp SM. The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability. BMJ Glob Health 2021; 5:bmjgh-2020-002296. [PMID: 32546585 PMCID: PMC7299037 DOI: 10.1136/bmjgh-2020-002296] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022] Open
Abstract
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.
Collapse
Affiliation(s)
| | - Caitlin Warthin
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lynn Freedman
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| |
Collapse
|
16
|
Krieger MGM, Wenham C, Nacif Pimenta D, Nkya TE, Schall B, Nunes AC, De Menezes A, Lotta G. How do community health workers institutionalise: An analysis of Brazil's CHW programme. Glob Public Health 2021; 17:1507-1524. [PMID: 34161201 DOI: 10.1080/17441692.2021.1940236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Community health workers (CHWs) are framed as the link between communities and the formal health system. CHWs must establish trusting relationships with the community and with the broader health service. How to find the optimal balance between the various strands of work for CHWs, and how to formalise this, has been the focus of different studies. We performed an extensive documentary analysis of federal legislation in Brazil to understand the institutionalisation of the CHW workforce in Brazil over the last 3 decades. The paper offers three contributions to the literature: the development and application of an analytical framework to consider the institutionalisation process of CHWs; a historical analysis of the professional institutionalisation of CHW in Brazil; and the identification of the paradoxes that such institutionalisation faces: firstly, institutionalisation focused on improving CHW remuneration created difficulties in hiring and paying these professionals; when CHW are incorporated within state bureaucracy they start to lose their autonomy as community agents; and that the effectiveness of CHW programmes depends on the improvement of clinical services in the most deprived areas.
Collapse
Affiliation(s)
| | | | | | - Theresia E Nkya
- Pan-Africa Mosquito Association, Nairobi, Kenya.,International Center of Insect Physiology and Ecology, Nairobi, Kenya.,College of Health and Allied Sciences, University of Dar es Salaam-Mbeya, Mbeya, Tanzania
| | - Brunah Schall
- Oswaldo Cruz Foundation - Fiocruz, Belo Horizonte, Brazil
| | | | - Ana De Menezes
- Department of Geography and Environment, LSE, London, UK
| | - Gabriela Lotta
- Getulio Vargas Foundation (FGV EAESP), Sao Paulo, Brazil
| |
Collapse
|
17
|
Ashebir F, Medhanyie AA, Mulugeta A, Persson LÅ, Berhanu D. Women's development group leaders' promotion of maternal, neonatal and child health care in Ethiopia: a cross-sectional study. Glob Health Action 2021; 13:1748845. [PMID: 32456555 PMCID: PMC7783097 DOI: 10.1080/16549716.2020.1748845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Women’s development group leaders are volunteer community health workers in Ethiopia who, among other duties, promote health and prevention of diseases. They link and extend essential health services from health posts to households. Objective To assess the characteristics, knowledge, and practice of women’s development group leaders in the field of maternal, neonatal, and child health care. Method This study used a cluster-sampled cross-sectional survey conducted from December 2016 to February 2017 in four regions of Ethiopia: Oromia, Amhara, Tigray and Southern Nations, Nationalities and Peoples. One of the volunteers, who was available at the time of the survey, was included from each cluster. A total of 187 women’s development group leaders participated in this quantitative study. Result Close to half of the women’s development group leaders were illiterate. The leaders had a wide variation in the number of women in their groups. Two-thirds had received some training during the last year, covering a broad range of health topics. Their knowledge of maternal, newborn, and child health was relatively low. Two-thirds had monthly contact with health extension workers. Around half had interacted with other local stakeholders on maternal and child health matters during the last three months. Two-thirds had visited pregnant women, and half had made home visits after delivery in the previous quarter. Activities regarding sick newborns and under-five children were less frequent. Conclusion The women leaders were given a wide range of tasks, despite having a low educational level and receiving training through brief orientations. They also showed limited knowledge but had a relatively high level of activities related to maternal health, while less so on neonatal and child health.
Collapse
Affiliation(s)
- Fisseha Ashebir
- Tigray Regional Health Bureau , Mekelle, Ethiopia.,College of Health Sciences, School of Public Health, Mekelle University , Mekelle, Ethiopia
| | - Araya Abrha Medhanyie
- College of Health Sciences, School of Public Health, Mekelle University , Mekelle, Ethiopia
| | - Afework Mulugeta
- College of Health Sciences, School of Public Health, Mekelle University , Mekelle, Ethiopia
| | - Lars Åke Persson
- London School of Hygiene & Tropical Medicine , London, UK.,Ethiopian Public Health Institute , Addis Ababa, Ethiopia
| | - Della Berhanu
- London School of Hygiene & Tropical Medicine , London, UK.,Ethiopian Public Health Institute , Addis Ababa, Ethiopia
| |
Collapse
|
18
|
Megersa BS, Bussmann H, Bärnighausen T, Muche AA, Alemu K, Deckert A. Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study. PLoS One 2020; 15:e0243036. [PMID: 33306681 PMCID: PMC7732077 DOI: 10.1371/journal.pone.0243036] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 11/15/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia. METHODS The study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women's development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study (in-depth interviews n = 22, four focus group discussions n = 25, 6-7 participants each). The study employed thematic analysis for clustering the emerged themes. RESULTS Husband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling. CONCLUSIONS Educating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings.
Collapse
Affiliation(s)
- Bikila Soboka Megersa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- * E-mail:
| | - Hermann Bussmann
- Department of Applied Tumor Biology, Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Achenef Asmamaw Muche
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Andreas Deckert
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| |
Collapse
|
19
|
Kurji J, Gebretsadik LA, Wordofa MA, Morankar S, Bedru KH, Bulcha G, Bergen N, Kiros G, Asefa Y, Asfaw S, Mamo A, Endale E, Thavorn K, Labonte R, Taljaard M, Kulkarni MA. Effectiveness of upgraded maternity waiting homes and local leader training on improving institutional births: a cluster-randomized controlled trial in Jimma, Ethiopia. BMC Public Health 2020; 20:1593. [PMID: 33092565 PMCID: PMC7583173 DOI: 10.1186/s12889-020-09692-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
Background Maternity waiting homes (MWHs), residential spaces for pregnant women close to obstetric care facilities, are being used to tackle physical barriers to access. However, their effectiveness has not been rigorously assessed. The objective of this cluster randomized trial was to evaluate the effectiveness of functional MWHs combined with community mobilization by trained local leaders in improving institutional births in Jimma Zone, Ethiopia. Methods A pragmatic, parallel arm cluster-randomized trial was conducted in three districts. Twenty-four primary health care units (PHCUs) were randomly assigned to either (i) upgraded MWHs combined with local leader training on safe motherhood strategies, (ii) local leader training only, or (iii) usual care. Data were collected using repeat cross-sectional surveys at baseline and 21 months after intervention to assess the effect of intervention on the primary outcome, defined as institutional births, at the individual level. Women who had a pregnancy outcome (livebirth, stillbirth or abortion) 12 months prior to being surveyed were eligible for interview. Random effects logistic regression was used to evaluate the effect of the interventions. Results Data from 24 PHCUs and 7593 women were analysed using intention-to-treat. The proportion of institutional births was comparable at baseline between the three arms. At endline, institutional births were slightly higher in the MWH + training (54% [n = 671/1239]) and training only arms (65% [n = 821/1263]) compared to usual care (51% [n = 646/1271]). MWH use at baseline was 6.7% (n = 256/3784) and 5.8% at endline (n = 219/3809). Both intervention groups exhibited a non-statistically significant higher odds of institutional births compared to usual care (MWH+ & leader training odds ratio [OR] = 1.09, 97.5% confidence interval [CI] 0.67 to 1.75; leader training OR = 1.37, 97.5% CI 0.85 to 2.22). Conclusions Both the combined MWH+ & leader training and the leader training alone intervention led to a small but non-significant increase in institutional births when compared to usual care. Implementation challenges and short intervention duration may have hindered intervention effectiveness. Nevertheless, the observed increases suggest the interventions have potential to improve women’s use of maternal healthcare services. Optimal distances at which MWHs are most beneficial to women need to be investigated. Trial registration The trial was retrospectively registered on the Clinical Trials website (https://clinicaltrials.gov) on 3rd October 2017. The trial identifier is NCT03299491.
Collapse
Affiliation(s)
- Jaameeta Kurji
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Lakew Abebe Gebretsadik
- Department of Health, Behaviour & Society, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | | | - Sudhakar Morankar
- Department of Health, Behaviour & Society, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | | | | | - Nicole Bergen
- Faculty of Health Sciences, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
| | - Getachew Kiros
- Department of Health, Behaviour & Society, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | - Yisalemush Asefa
- Department of Health Economics, Management & Policy, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | - Shifera Asfaw
- Department of Health, Behaviour & Society, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | - Abebe Mamo
- Department of Health, Behaviour & Society, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | - Erko Endale
- Department of Health, Behaviour & Society, Jimma University, Jimma Town, Jimma Zone, Ethiopia
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute General Campus, University of Ottawa, Ottawa, Canada
| | - Ronald Labonte
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute Civic Campus, University of Ottawa, Ottawa, Canada
| | - Manisha A Kulkarni
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
| |
Collapse
|
20
|
Arora N, Hanson K, Spicer N, Estifanos AS, Keraga DW, Welearegay AT, Tela FG, Hussen YA, Mandefro YS, Quaife M. Understanding the importance of non-material factors in retaining community health workers in low-income settings: a qualitative case-study in Ethiopia. BMJ Open 2020; 10:e037989. [PMID: 33033092 PMCID: PMC7545659 DOI: 10.1136/bmjopen-2020-037989] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The motivation and retention of community health workers (CHWs) is a challenge and inadequately addressed in research and policy. We sought to identify factors influencing the retention of CHWs in Ethiopia and ways to avert their exit. DESIGN A qualitative study was undertaken using in-depth interviews with the study participants. Interviews were audio-recorded, and then simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 using an iterative inductive-deductive approach. SETTING The study was conducted in two districts each in the Tigray and Southern Nations, Nationalities and People's Republic (SNNPR) regions in Ethiopia. Respondents were located in a mix of rural and urban settings. PARTICIPANTS Leavers of health extension worker (HEW) positions (n=20), active HEWs (n=16) and key informants (n=11) in the form of policymakers were interviewed. RESULTS We identified several extrinsic and intrinsic motivational factors affecting the retention and labour market choices of HEWs. While financial incentives in the form of salaries and material incentives in the form of improvements to health facility infrastructure, provision of childcare were reported to be important, non-material factors like HEWs' self-image, acceptance and validation by the community and their supervisors were found to be critical. A reduction or loss of these non-material factors proved to be the catalyst for many HEWs to leave their jobs. CONCLUSION Our study contributes new empirical evidence to the global debate on factors influencing the motivation and retention of CHWs, by being the first to include job leavers in the analysis. Our findings suggest that policy interventions that appeal to the social needs of CHWs can prove to be more acceptable and potentially cost-effective in improving their retention in the long run. This is important for government policymakers in resource constrained settings like Ethiopia that rely heavily on lay workers for primary healthcare delivery.
Collapse
Affiliation(s)
- Nikita Arora
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kara Hanson
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Neil Spicer
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
21
|
Political connections and psychosocial wellbeing among Women's Development Army leaders in rural amhara, Ethiopia: Towards a holistic understanding of community health workers' socioeconomic status. Soc Sci Med 2020; 266:113373. [PMID: 33068871 DOI: 10.1016/j.socscimed.2020.113373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 11/20/2022]
Abstract
Little empirical research exists on the effects of health work on Community Health Workers' (CHWs') social relationships and status, yet these factors are important in understanding the broad social and behavioral drivers and impacts of CHW programs. This is particularly true for unpaid CHWs. Engaging with others as a CHW might help a worker to embody a valued role in society as a selfless, caring individual; or it might strengthen bonds with others and improve social networks and social capital. By combining qualitative, ethnographic, and survey data collected in rural Amhara, Ethiopia from 2013 to 2016, we evaluated the extent to which unpaid female workers in Ethiopia's Women's Development Army (WDA) were better able than their peers to achieve cultural consonance by building desired social connections or fulfilling locally salient models of virtuous womanhood. We conducted a cultural consensus survey (n = 74) and measured cultural consonance in a larger survey of adult women, including WDA leaders (n = 422). We also conducted participant observation and interviews with health officials, local health staff, and WDA leaders. In our study site, WDA leaders were more able than other women to fulfill the cultural ideal of having connections to various government officials. Yet these connections often did not lead to the benefits that WDA leaders hoped for. Also, in contrast to the findings of many other studies, achieving greater cultural consonance was not significantly associated with reduced psychological distress in this population. For women in this rural context, meanwhile, psychological distress is strongly associated with food and water insecurity, stressful life events, and social support. These findings point to the importance of social, economic and psychological support for rural women in Amhara, and specifically for unpaid CHWs.
Collapse
|
22
|
Sacks E, Schleiff M, Were M, Chowdhury AM, Perry HB. Communities, universal health coverage and primary health care. Bull World Health Organ 2020; 98:773-780. [PMID: 33177774 PMCID: PMC7607457 DOI: 10.2471/blt.20.252445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/27/2022] Open
Abstract
Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.
Collapse
Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| | - Meike Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| | | | | | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| |
Collapse
|
23
|
Wall JT, Kaiser BN, Friis-Healy EA, Ayuku D, Puffer ES. What about lay counselors' experiences of task-shifting mental health interventions? Example from a family-based intervention in Kenya. Int J Ment Health Syst 2020; 14:9. [PMID: 32099580 PMCID: PMC7031864 DOI: 10.1186/s13033-020-00343-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/03/2020] [Indexed: 12/24/2022] Open
Abstract
Background A key focus of health systems strengthening in low- and middle-income countries is increasing reach and access through task-shifting. As such models become more common, it is critical to understand the experiences of lay providers because they are on the forefront for delivering care services. A greater understanding would improve lay provider support and help them provide high-quality care. This is especially the case for those providing mental health services, as providing psychological care may pose unique stressors. We sought to understand experiences of lay counselors, focusing on identity, motivation, self-efficacy, stress, and burnout. The goal was to understand how taking on a new provider role influences their lives beyond simply assuming a new task, which would in turn help identify actionable steps to improve interventions with task-shifting components. Methods Semi-structured interviews (n = 20) and focus group discussions (n = 3) were conducted with three lay counselor groups with varying levels of experience delivering a community-based family therapy intervention in Eldoret, Kenya. Thematic analysis was conducted, including intercoder reliability checks. A Stress Map was created to visualize stress profiles using free-listing and pile-sorting data collected during interviews and focus group discussions. Results Counselors described high intrinsic motivation to become counselors and high self-efficacy after training. They reported positive experiences in the counselor role, with new skills improving their counseling and personal lives. As challenges arose, including client engagement difficulties and balancing many responsibilities, stress and burnout increased, dampening motivation and self-efficacy. In response, counselors described coping strategies, including seeking peer and supervisor support, that restored their motivation to persevere. At case completion, they again experienced high self-efficacy and a desire to continue. Conclusions Findings informed suggestions for ways to incorporate support for lay providers into task-shifting interventions at initiation, during training, and throughout implementation. These include acknowledging and preparing counselors for challenges during training, increasing explicit attention to counselor stress in supervision, fostering peer support among lay providers, and ensuring a fair balance between workload and compensation. Improving and building an evidence base around practices for supporting lay providers will improve the effectiveness and sustainability of lay provider-delivered interventions.
Collapse
Affiliation(s)
| | - Bonnie N Kaiser
- 1Duke University, Durham, NC USA.,2University of California San Diego, La Jolla, CA USA
| | | | - David Ayuku
- 3Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | | |
Collapse
|
24
|
Kelly A, Mitra S, Elung'at J, Songok J, Jackson S, Christoffersen-Deb A. Can the financial burden of being a community health volunteer in western Kenya exacerbate poverty? Health Promot Int 2020; 35:93-101. [PMID: 30590528 DOI: 10.1093/heapro/day110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Community health volunteers (CHVs) act as vital links between communities and health facilities, bridging the health service delivery gap common in low- and middle-income countries. In 2013, changes in funding in western Kenya left most CHVs without their individual monthly stipend. In this article, we explore how the implementation of a pooled incentive model had an impact on the lives of CHVs from two counties in western Kenya. Participation in this form of table banking was meant to allow CHVs to pool their resources together and invest in income-generating activities to offset the costs of unpaid health work. A pre-post qualitative study, consisting of focus group discussions and in-depth interviews explored CHV compensation, motivations and challenges experienced in 2013 and 2015, prior to and after the implementation of this pooled incentive model. Following withdrawal of the monthly stipend, we found that CHVs continued to take on roles and responsibilities of paid health workers, motivated by shared social identities and connections to their communities. However, replacing the stipend with a pooled-group incentive model seemingly exacerbated the financial burden already experienced by this vulnerable population. This study brings into question the sustainability and viability of a volunteer community health worker programme and highlights the need to address the financial burden associated with the CHV role in western Kenya.
Collapse
Affiliation(s)
- Alyssa Kelly
- Centre for Addiction and Mental Health, Department of Education, Toronto, Canada
| | - Sanjana Mitra
- University of British Columbia, Interdisciplinary Studies Graduate Program, Vancouver, Canada
| | - Justus Elung'at
- Academic Model Providing Access to Healthcare (AMPATH), Primary Healthcare, Eldoret, Kenya
| | - Julia Songok
- Academic Model Providing Access to Healthcare (AMPATH), Primary Healthcare, Eldoret, Kenya.,Moi University College of Health Sciences, Eldoret, Kenya
| | - Suzanne Jackson
- University of Toronto, Dalla Lana School of Public Health, Department of Social and Behavioural Sciences (Health Promotion), Toronto, Ontario, Canada
| | - Astrid Christoffersen-Deb
- Academic Model Providing Access to Healthcare (AMPATH), Primary Healthcare, Eldoret, Kenya.,Moi University College of Health Sciences, Eldoret, Kenya.,University of Toronto, Faculty of Medicine, Department of Obstetrics and Gynaecology, Toronto, Ontario, Canada
| |
Collapse
|
25
|
Closser S, Napier H, Maes K, Abesha R, Gebremariam H, Backe G, Fossett S, Tesfaye Y. Does volunteer community health work empower women? Evidence from Ethiopia’s Women’s Development Army. Health Policy Plan 2019; 34:298-306. [DOI: 10.1093/heapol/czz025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia’s Women’s Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands—and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA—that women’s empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy—allowed the Ethiopian government and its donors to pursue ‘empowerment’ without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.
Collapse
Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, USA
| | - Harriet Napier
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, USA
| | - Kenneth Maes
- Department of Anthropology, Oregon State University, 2250 SW Jefferson Way, Corvallis, OR, USA
| | - Roza Abesha
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Hana Gebremariam
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Grace Backe
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Sarah Fossett
- Department of Sociology/Anthropology, Middlebury College, 201 Munroe Hall, Middlebury, VT, USA
| | - Yihenew Tesfaye
- Department of Anthropology, Oregon State University, 2250 SW Jefferson Way, Corvallis, OR, USA
| |
Collapse
|
26
|
Rieger M, Wagner N, Mebratie A, Alemu G, Bedi A. The impact of the Ethiopian health extension program and health development army on maternal mortality: A synthetic control approach. Soc Sci Med 2019; 232:374-381. [PMID: 31136888 DOI: 10.1016/j.socscimed.2019.05.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/14/2019] [Accepted: 05/21/2019] [Indexed: 11/25/2022]
Abstract
The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.
Collapse
Affiliation(s)
- Matthias Rieger
- International Institute of Social Studies, Erasmus University Rotterdam, P.O. Box 29776, 2502 LT, The Hague, the Netherlands.
| | - Natascha Wagner
- International Institute of Social Studies, Erasmus University Rotterdam, P.O. Box 29776, 2502 LT, The Hague, the Netherlands
| | - Anagaw Mebratie
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Alemu
- Institute of Development and Policy Research, Addis Ababa University, Addis Ababa, Ethiopia
| | - Arjun Bedi
- International Institute of Social Studies, Erasmus University Rotterdam, P.O. Box 29776, 2502 LT, The Hague, the Netherlands
| |
Collapse
|
27
|
Bergen N, Ruckert A, Kulkarni MA, Abebe L, Morankar S, Labonté R. Subnational health management and the advancement of health equity: a case study of Ethiopia. Glob Health Res Policy 2019; 4:12. [PMID: 31131331 PMCID: PMC6524326 DOI: 10.1186/s41256-019-0105-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/09/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development, and a priority in health sector planning in countries including Ethiopia. Subnational health managers in Ethiopia are uniquely positioned to advance health equity, given the coordination, planning, budgetary, and administration tasks that they are assigned. Yet, the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched. This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity. METHODS A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional, zonal, district and Primary Health Care Unit administrative levels. Twelve in-depth interviews were conducted with directors, vice-directors, coordinators and technical experts. Data were analyzed using thematic analysis. RESULTS Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities, especially when they intersected with poor infrastructure, patriarchal gender norms, unequal support from non-governmental organizations or challenging topography. Participants used ad hoc, context-specific strategies (such as resource-pooling with other sectors or groups and shaming-as-motivation) to improve health service delivery to remote populations and strengthen health system operations. Collaboration with other groups facilitated cost sharing and access to resources; however, the opportunities afforded by these collaborations, were not realized equally in all areas. Subnational health managers' efforts in promoting health equity are affected by inadequate resource availability, which restricts their ability to enact long-term and sustainable solutions. CONCLUSIONS Advancing health equity in Ethiopia requires: extra support to communities in hard-to-reach areas; addressing patriarchal norms; and strategic aligning of the subnational health system with non-health government sectors, community groups, and non-governmental organizations. The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity, and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.
Collapse
Affiliation(s)
- Nicole Bergen
- University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - Arne Ruckert
- University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | | | - Lakew Abebe
- Jimma University, PO Box 378, Jimma, Ethiopia
| | | | - Ronald Labonté
- University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| |
Collapse
|
28
|
Maes K, Closser S, Tesfaye Y, Abesha R. Psychosocial distress among unpaid community health workers in rural Ethiopia: Comparing leaders in Ethiopia's Women's Development Army to their peers. Soc Sci Med 2019; 230:138-146. [PMID: 31009880 DOI: 10.1016/j.socscimed.2019.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 11/28/2022]
Abstract
There is a growing critical social science literature on volunteering in health programs in non-western, low-income countries, yet few have mixed quantitative and qualitative methods to examine the psychological and social wellbeing of unpaid community health workers in such contexts. We address this issue with data from unpaid community health workers (CHWs) and other women who comprise Ethiopia's state-organized Women's Development Army. We draw on qualitative and cross-sectional survey data collected between 2013 and 2016 to test links between various aspects of psychosocial and economic wellbeing and volunteer status in a rural context. We surveyed 422 adult women in Amhara state, 73 of whom were unpaid CHWs in the "Army". We also conducted interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women. Analyses of our qualitative and quantitative datasets show that volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects, and that CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women-especially unmarried women-vulnerable to negative gossip and high levels of psychological distress. To a limited extent, the volunteer CHW position also bolsters married women's subjective socioeconomic status and confidence in achieving future gains in status. By showing that unpaid CHWs do not necessarily enjoy psychosocial benefits, and may experience harm as a result of their work, these findings reinforce the recommendation that CHWs in contexts of poverty be paid and better supported.
Collapse
Affiliation(s)
- Kenneth Maes
- Department of Anthropology, Oregon State University, Corvallis, OR, USA.
| | - Svea Closser
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Yihenew Tesfaye
- Department of Anthropology, Oregon State University, Corvallis, OR, USA
| | | |
Collapse
|
29
|
Brewis A, Rosinger A, Wutich A, Adams E, Cronk L, Pearson A, Workman C, Young S. Water sharing, reciprocity, and need: A comparative study of interhousehold water transfers in sub-Saharan Africa. ECONOMIC ANTHROPOLOGY 2019. [DOI: 10.1002/sea2.12143] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Alexandra Brewis
- School of Human Evolution and Social Change; Arizona State University; Tempe AZ 85287 USA
| | - Asher Rosinger
- Department of Biobehavioral Health and Department of Anthropology; Penn State University, University Park; PA 16802 USA
| | - Amber Wutich
- School of Human Evolution and Social Change; Arizona State University; Tempe AZ 85287 USA
| | - Ellis Adams
- Global Studies Institute and Department of Geosciences; Georgia State University; Atlanta GA 30303 USA
| | - Lee Cronk
- Department of Anthropology; Rutgers University; New Brunswick NJ 08901 USA
| | - Amber Pearson
- Department of Geography, Environment and Spatial Sciences; Michigan State University; East Lansing MI 48824 USA
| | - Cassandra Workman
- Department of Sociology and Anthropology; North Carolina State University; Raleigh, NC 27695 USA
| | - Sera Young
- Department of Anthropology; Northwestern University, Evanston; IL 60208 USA
| | | |
Collapse
|
30
|
Mohajer N, Singh D. Factors enabling community health workers and volunteers to overcome socio-cultural barriers to behaviour change: meta-synthesis using the concept of social capital. HUMAN RESOURCES FOR HEALTH 2018; 16:63. [PMID: 30463573 PMCID: PMC6249815 DOI: 10.1186/s12960-018-0331-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 11/06/2018] [Indexed: 05/30/2023]
Abstract
BACKGROUND Community-based health workers and volunteers are not just low-level health workforce; their effectiveness is also due to their unique relationship with the community and is often attributed to social capital, an area not well studied or acknowledged in the literature. METHODS A qualitative meta-synthesis was conducted using the SPIDER framework and based on critical interpretive synthesis. The protocol was registered with PROSPERO, ID = CRD42018084130. This article reports on the qualitative data extracted from the final 33 articles selected from 147 full-text articles on social capital and community-based health systems. RESULTS Three constructs were identified that enable community health workers to bring about changes in behaviour in the community: seeing their role as a service or a calling motivated by altruistic values, accompanying community members on their journey and the aim of the journey being empowerment rather than health. Community health workers feel under-resourced to provide for expectations from the community, to fulfil their non-health needs, to meet the expectations of their employers and to be able to deliver health services. CONCLUSION The dichotomy of needs between the community and health services can be resolved if policy makers and programme designers examine the possibility of two cadres of community-based health workforce: full-time workers and part-time volunteers, with clear scopes of practice and supervision. Community health workers would primarily be concerned with task shifting roles demanded by programmes, and volunteers can focus on the wider empowerment-based needs of communities.
Collapse
Affiliation(s)
- Nicole Mohajer
- School of Public Health, College of Health and Medical Sciences, Haramaya University, P.O. BOX 138, 3020, Dire Dawa, Ethiopia.
| | - Debra Singh
- Child and Adolescent Health Service, Health Department, Government of Western Australia, 189 Royal Street, East Perth, WA, 6004, Australia
| |
Collapse
|
31
|
Bezabih AM, Wereta MH, Kahsay ZH, Getahun Z, Bazzano AN. Demand and Supply Side Barriers that Limit the Uptake of Nutrition Services among Pregnant Women from Rural Ethiopia: An Exploratory Qualitative Study. Nutrients 2018; 10:E1687. [PMID: 30400650 PMCID: PMC6267174 DOI: 10.3390/nu10111687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/29/2018] [Accepted: 11/01/2018] [Indexed: 11/21/2022] Open
Abstract
Despite poverty reduction and increased promotion of improved nutrition practices in the community, undernutrition in Ethiopia remains a concern. The present study aimed to explore the demand and supply side barriers that limit the uptake of nutrition services among pregnant women from the rural communities of the Tigray Region, Northern Ethiopia. A community-based qualitative study was conducted in December through January 2017. A total of 90 key informant in-depth interviews and 14 focus group discussions were undertaken. Study participants were purposively selected for specific characteristics, along with health professionals deployed at various levels of the health system, including health posts, health centers, woreda health offices, and the regional health bureau. Study participants were asked to identify the barriers and implementation challenges that limit access to nutrition services for pregnant women. Participants' responses were transcribed verbatim, without editing the grammar, to avoid losing meaning. The data were imported to ATLAS.ti 7 (qualitative data analysis software) for coding and analyzed using a thematic content analysis approach. The study findings indicated that the dietary quality of pregnant women in the study area remains poor and in some cases, poorer quality than pre-pregnancy. Across study sites, heavy workloads, food taboos and avoidances, low husband support, lack of economic resources, lack of awareness, low educational level of women, poor dietary habits, increased expenditure for cultural and religious festivities, "dependency syndrome", low physical access to health facilities, poorly equipped health facilities, focus on child health and nutrition, poor coordination among nutrition specific and sensitive sectors, and limited sources of nutrition information were identified as the demand and supply side barriers limiting the uptake of nutrition services during pregnancy. In conclusion, the community would benefit from improved social behavior change communication on nutrition during pregnancy and multi-sectoral coordination among nutrition-specific and nutrition-sensitive sectors.
Collapse
Affiliation(s)
- Afework Mulugeta Bezabih
- Department of Nutrition and Dietetics, School of Public Health, College of Health Sciences, Mekelle University, P. O. Box 1871, Mekelle, Ethiopia.
| | - Mekonnen Haileselassie Wereta
- Department of Nutrition and Dietetics, School of Public Health, College of Health Sciences, Mekelle University, P. O. Box 1871, Mekelle, Ethiopia.
| | - Znabu Hadus Kahsay
- Department of Nutrition and Dietetics, School of Public Health, College of Health Sciences, Mekelle University, P. O. Box 1871, Mekelle, Ethiopia.
| | | | - Alessandra N Bazzano
- Tulane University School of Public Health, Department of Global Community Health and Behavioral Sciences, New Orleans, LA 70125, USA.
| |
Collapse
|
32
|
Wutich A, Budds J, Jepson W, Harris L, Adams E, Brewis A, Cronk L, DeMyers C, Maes K, Marley T, Miller J, Pearson A, Rosinger A, Schuster R, Stoler J, Staddon C, Wiessner P, Workman C, Young S. Household water sharing: A review of water gifts, exchanges, and transfers across cultures. WIRES. WATER 2018; 5:e1309. [PMID: 30858971 PMCID: PMC6407694 DOI: 10.1002/wat2.1309] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Water sharing offers insight into the everyday and, at times, invisible ties that bind people and households with water and to one another. Water sharing can take many forms, including so-called "pure gifts," balanced exchanges, and negative reciprocity. In this paper, we examine water sharing between households as a culturally-embedded practice that may be both need-based and symbolically meaningful. Drawing on a wide-ranging review of diverse literatures, we describe how households practice water sharing cross-culturally in the context of four livelihood strategies (hunter-gatherer, pastoralist, agricultural, and urban). We then explore how cross-cutting material conditions (risks and costs/benefits, infrastructure and technologies), socio-economic processes (social and political power, water entitlements, ethnicity and gender, territorial sovereignty), and cultural norms (moral economies of water, water ontologies, and religious beliefs) shape water sharing practices. Finally, we identify five new directions for future research on water sharing: conceptualization of water sharing; exploitation and status accumulation through water sharing, biocultural approaches to the health risks and benefits of water sharing, cultural meanings and socio-economic values of waters shared; and water sharing as a way to enact resistance and build alternative economies.
Collapse
Affiliation(s)
| | | | | | | | - Ellis Adams
- PO Box 872402 Tempe 85287-2402, United States
| | | | - Lee Cronk
- PO Box 872402 Tempe 85287-2402, United States
| | | | | | | | | | | | | | | | | | | | | | | | - Sera Young
- PO Box 872402 Tempe 85287-2402, United States
| |
Collapse
|