1
|
Riang'a RM, Nyanja N, Lusambili A, Mwangi EM, Ehrlich JR, Clyde P, Mostert C, Ngugi A. Implementation framework for income generating activities identified by community health volunteers (CHVs): a strategy to reduce attrition rate in Kilifi County, Kenya. BMC Health Serv Res 2024; 24:132. [PMID: 38267980 PMCID: PMC10809497 DOI: 10.1186/s12913-023-10514-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Despite the proven efficacy of Community Health Volunteers (CHVs) in promoting primary healthcare in low- and middle-income countries (LMICs), they are not adequately financed and compensated. The latter contributes to the challenge of high attrition rates observed in many settings, highlighting an urgent need for innovative compensation strategies for CHVs amid budget constraints experienced by healthcare systems. This study sought to identify strategies for implementing Income-Generating Activities (IGAs) for CHVs in Kilifi County in Kenya to improve their livelihoods, increase motivation, and reduce attrition. METHODS An exploratory qualitative research study design was used, which consisted of Focus group discussions with CHVs involved in health promotion and data collection activities in a local setting. Further, key informant in-depth interviews were conducted among local stakeholder representatives and Ministry of Health officials. Data were recorded, transcribed and thematically analysed using MAXQDA 20.4 software. Data coding, analysis and presentation were guided by the Okumus' (2003) Strategy Implementation framework. RESULTS A need for stable income was identified as the driving factor for CHVs seeking IGAs, as their health volunteer work is non-remunerative. Factors that considered the local context, such as government regulations, knowledge and experience, culture, and market viability, informed their preferred IGA strategy. Individual savings through table-banking, seeking funding support through loans from government funding agencies (e.g., Uwezo Fund, Women Enterprise Fund, Youth Fund), and grants from corporate organizations, politicians, and other donors were proposed as viable options for raising capital for IGAs. Formal registration of IGAs with Government regulatory agencies, developing a guiding constitution, empowering CHVs with entrepreneurial and leadership skills, project and group diversity management, and connecting them to support agencies were the control measures proposed to support implementation and enhance the sustainability of IGAs. Group-owned and managed IGAs were preferred over individual IGAs. CONCLUSION CHVs are in need of IGAs. They proposed implementation strategies informed by local context. Agencies seeking to support CHVs' livelihoods should, therefore, engage with and be guided by the input from CHVs and local stakeholders.
Collapse
Affiliation(s)
- Roselyter Monchari Riang'a
- Department of Population Health, Aga Khan University, East Africa, Medical College, 3rd Parklands Avenue, off Limuru Road, Nairobi, 30270-00100, Kenya.
| | - Njeri Nyanja
- Department of Family Medicine, Aga Khan University, East Africa, Nairobi, Kenya
| | - Adelaide Lusambili
- Institute for Human Development, Aga Khan University, East Africa, Nairobi, Kenya
| | - Eunice Muthoni Mwangi
- Department of Population Health, Aga Khan University, East Africa, Medical College, 3rd Parklands Avenue, off Limuru Road, Nairobi, 30270-00100, Kenya
| | - Joshua R Ehrlich
- Department of Ophthalmology and Visual Sciences, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Paul Clyde
- The William Davidson Institute at the University of Michigan and the Ross School of Business, University of Michigan, Ann Arbor, MI, USA
| | - Cyprian Mostert
- Department of Population Health, Aga Khan University, East Africa, Medical College, 3rd Parklands Avenue, off Limuru Road, Nairobi, 30270-00100, Kenya
- Aga Khan University, East Africa, Brain and Mind Institute, Nairobi, Kenya
| | - Anthony Ngugi
- Department of Population Health, Aga Khan University, East Africa, Medical College, 3rd Parklands Avenue, off Limuru Road, Nairobi, 30270-00100, Kenya
| |
Collapse
|
2
|
Pallikkuth R, Manoj Kumar T, Dictus CT, Bunders-Aelen JFG. Design and Evaluation of Peer Supervision for Community Mental Health Workers: A Task-Shifting Strategy in Low-Resource Settings. Community Ment Health J 2024; 60:131-147. [PMID: 37679654 PMCID: PMC10799819 DOI: 10.1007/s10597-023-01161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 06/17/2023] [Indexed: 09/09/2023]
Abstract
The use of Lay Mental Health Workers (LMHWs) to tackle the treatment gap in low-resource settings is well established, and although they often receive training, the potential of proper supervision to improve outcomes remains untapped. Indeed, given the strain on expert resources, peer-supervision models based on supervisors' seniority of work experience have significant potential especially in relation to community knowledge and embedding of LMHWs. This study summarizes the evaluation of a pilot program for peer supervision on the basis of Social Cognitive Theories of Self-Efficacy for LMHWs in Kerala, India. Two experienced LMHWs worked as supervisors for a total of 12 LMHWs over the course of a year. These participants were subsequently interviewed to analyze their experiences in order to evaluate the potential of peer supervision and distil relevant information to improve future training of LMHWs. The findings include improved performance and emotional support for the participants.
Collapse
Affiliation(s)
- Rekha Pallikkuth
- Department of Clinical Psychology, Mental Health Action Trust, Calicut, India
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - T Manoj Kumar
- Department of Clinical Psychology, Mental Health Action Trust, Calicut, India
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Claudia T Dictus
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands.
| | | |
Collapse
|
3
|
Santosh S, Kane S. Extending Kingdon's Multiple Streams Policy Framework Through an Analysis of How Community Health Workers in India Are Driving Policy Changes. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2023:2752535X231222654. [PMID: 38105229 DOI: 10.1177/2752535x231222654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
In this paper we develop and provide a novel account of the process through which the Accredited Social Health Activists (ASHAs), a cadre of seemingly powerless community health workers in India, are navigating a complex policy process to incrementally achieve their goals. ASHAs have been demanding better working conditions, better compensation, and regularisation as public service employees through protests and strikes and have managed to gain concessions from both the Central and various State governments. We observed two important aspects that emerged: (a) ASHAs achieved incremental increases in their wages despite being the lowest in the health system hierarchy, and, (b) major gains were made during the 2 years of the pandemic. We examine and analyse ASHAs' engagement and strategies used, both overt and covert, sometimes with the government, and the role of other actors in determining these policy outcomes. We do so by drawing on academic literature and news media reports; we trace the changes in ASHAs' wages by tying together key events, 'windows of opportunity', and actions of 'policy entrepreneurs' involved in the process.In doing so, we further develop and propose an extension to Kingdon's multiple streams policy framework through the addition of a 'narrative stream'.
Collapse
Affiliation(s)
- Sanjana Santosh
- Centre for Health Policy and Systems, Gokhale Institute of Politics and Economics, Pune, India
| | - Sumit Kane
- Centre for Health Policy and Systems, Gokhale Institute of Politics and Economics, Pune, India
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
4
|
Matsi MM, Lekalakala-Mokgele ES, Madumo MM. Community health workers' experiences of supervision by nurses at clinics in Limpopo Province. Health SA 2023; 28:2330. [PMID: 38204862 PMCID: PMC10778378 DOI: 10.4102/hsag.v28i0.2330] [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: 01/28/2023] [Accepted: 09/06/2023] [Indexed: 01/12/2024] Open
Abstract
Background Supervision of community health workers (CHWs) is considered, among others, a strategy to achieve universal healthcare globally. In South Africa, it is incorporated in the ward-based primary healthcare (PHC) outreach teams' policy and strategy, a national health insurance policy component. Supervision of CHWs by nurses in the policy is considered a measure to facilitate PHC service provision to communities. However, CHWs experienced varying levels of supervision from nurses and other workers globally and in South Africa. Aim This study explored and described the experiences of CHWs about supervision received from nurses at PHC facilities in Limpopo Province. Setting Participants were drawn from seven PHC facilities in Polokwane and Lepelle-Nkumpi subdistricts of the Capricorn District. Methods A qualitative exploratory-descriptive and contextual study design was employed. Participants were selected utilising a purposive sampling method. Semi-structured interviews were conducted to collect data. Data were analysed according to themes and their associated categories. Measures to ensure rigour and ethical principles were applied. Results Two main themes emerged: positive supervision experienced by CHWs and supervision challenges experienced by CHWs. Conclusion The varying experiences of CHWs about supervision from nurses emerged and reflected the need for functioning supervision mechanisms. Contribution The experiences of CHWs indicated inconsistent delivery of supervision by nurses in PHC facilities. The findings highlighted the need for effective supervision measures that are vital for the success of the CHW supervision programme.
Collapse
Affiliation(s)
- Makwena M Matsi
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Eucebious S Lekalakala-Mokgele
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mary M Madumo
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
5
|
Mallaiah J, Leon RD, Williams O, Allegrante JP. Cardiovascular Disease and Stroke-Focused Competency Assessment Tools for Community Health Workers in the United States: A Scoping Review. Health Promot Pract 2023; 24:1183-1195. [PMID: 36062599 DOI: 10.1177/15248399221120809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cardiovascular disease (CVD) and stroke are major contributors to chronic disease burden in the United States. Despite the high prevalence of stroke, 90% of all stroke events are preventable and can be attributed to seven key modifiable risk factors (MRFs)-high blood pressure (BP), high cholesterol, diabetes mellitus (DM), smoking, obesity, unhealthy diet, and physical inactivity. In the United States, stroke prevention interventions led by community health workers (CHWs) have been proven to be highly effective in preventing the onset of MRFs. We conducted a scoping review of the competency assessment methods used in CVD and stroke-focused CHW training programs. We searched six online databases: PubMed, Cochrane, CINAHL, Embase, Web of Science, and HaPI, from all available years until January 2021. Of the 1,774 initial articles found, we identified 30 eligible articles to be included in the review. Nine of these studies used previously validated instruments, whereas the remaining 21 studies used tools from the training curriculum or independently developed instruments. Only five of these validated tools reported psychometric properties; none of them were designed for the CHW population. Our scoping review of literature revealed that CHW-specific competency assessment methods were limited, with few or no domain-referenced tools on CVD or stroke risk factors that complied with established measurement standards. We conclude that there is an urgent need for the development of a comprehensive and valid assessment instrument in CVD and stroke prevention to evaluate CHW performance and optimize their credibility, representing important first steps toward integrating CHWs into health care systems.
Collapse
|
6
|
Wennerstrom A, Smith DO. Labour exploitation among community health workers. Lancet Glob Health 2023; 11:e1484-e1485. [PMID: 37734782 DOI: 10.1016/s2214-109x(23)00409-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Ashley Wennerstrom
- Department of Behavioral and Community Health Sciences, School of Public Health, LSU Health-New Orleans, New Orleans, LA 70112, USA.
| | - Denise Octavia Smith
- National Association of Community Health Workers, Boston, MA, USA; Primary Care Program in Global Primary Care and Social Change, Harvard Medical School, Havard University, Boston, MA, USA
| |
Collapse
|
7
|
Betrian M, Umans D, Vanna M, Ol S, Adhikari B, Davoeung C, Callery JJ, Sovann Y, Peto TJ, Maude RJ, van der Pluijm RW, Bunreth V, Grobusch MP, van Vugt M, Lubell Y, von Seidlein L, Dondorp AM, Sovannaroth S, Lek D, Tripura R. Expanding the role of village malaria workers in Cambodia: Implementation and evaluation of four health education packages. PLoS One 2023; 18:e0283405. [PMID: 37682947 PMCID: PMC10490887 DOI: 10.1371/journal.pone.0283405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Early access to correct diagnosis and appropriate treatment is essential for malaria elimination, and in Cambodia this relies on village malaria workers (VMWs). Decreasing malaria transmission leave VMWs with diminished roles. Activities related to the control of other health conditions could keep these community health workers relevant. METHODS During 2022, 120 VMWs attended training at local health centres on four health education packages: 1. hygiene and sanitation; 2. disease surveillance; 3. management of mild illness; 4. vaccination and antenatal care. All training and evaluation sessions were documented through meeting minutes, and 19 focus group discussions (FGDs) were conducted among VMWs and health centre personnel. Audio-records of FGDs were transcribed and translated in English and underwent thematic analysis. RESULTS VMWs reported strong interest in the training and welcomed the expansion of their roles thus assuring their continued relevance. VMWs prioritized disease surveillance and management of mild illness among the available training packages because these topics were seen as most relevant. While training was considered comprehensible and important, the low literacy among VMWs was an impediment suggesting training materials need to be delivered visually. Since VMWs have limited resources, incentives could ensure that VMWs are motivated to undertake additional roles and responsibilities. CONCLUSIONS The transformation of VMWs into community health workers with roles beyond malaria is a promising approach for sustaining health care provision in remote areas. Training needs to consider the low scientific literacy, time constraints and limited resources of VMWs.
Collapse
Affiliation(s)
- Mipharny Betrian
- Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centres, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dafne Umans
- Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centres, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moul Vanna
- Action for Health and Development, Battambang Province, Battambong Municipality, Cambodia
| | - Sam Ol
- Action for Health and Development, Battambang Province, Battambong Municipality, Cambodia
| | - Bipin Adhikari
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chan Davoeung
- Battambang Provincial Health Department, Battambang Province, Battambong Municipality, Cambodia
| | - James J. Callery
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yok Sovann
- Pailin Provincial Health Department, Pailin Province, Pailin Municipality, Cambodia
| | - Thomas J. Peto
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Richard J. Maude
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- The Open University, Milton Keynes, Buckinghamshire, United Kingdom
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Rob W. van der Pluijm
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Voeunrung Bunreth
- Battambang Provincial Health Department, Battambang Province, Battambong Municipality, Cambodia
| | - Martin P. Grobusch
- Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centres, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michèle van Vugt
- Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centres, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lorenz von Seidlein
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M. Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Siv Sovannaroth
- National Centre for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
| | - Dysoley Lek
- National Centre for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Rupam Tripura
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
8
|
Ogutu MO, Kamui E, Abuya T, Muraya K. "We are their eyes and ears here on the ground, yet they do not appreciate us"-Factors influencing the performance of Kenyan community health volunteers working in urban informal settlements. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001815. [PMID: 37578950 PMCID: PMC10424859 DOI: 10.1371/journal.pgph.0001815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023]
Abstract
This study explored factors that influence CHV performance in urban informal settlements (UIS) within Nairobi Kenya and ways in which CHVs can be supported to enhance their wellbeing and strengthen community strategies. The study was undertaken in two UIS within Nairobi County. Thirteen focus group discussions and three key informant interviews were conducted with a range of respondents. Various topics covering the design of the Community Health Strategy (CHS) and broader contextual factors that affect CHVs' performance, were discussed and data analysed using a framework analysis approach. The key programme design factors identified as influencing the performance of CHVs working in UIS included: CHV recruitment; training; availability of supplies and resources; and remuneration of CHVs. Health system factors that influenced CHVs performance included: nature of relationship between healthcare workers at local referral facilities and community members; availability of services and perceived corruption at referral facilities; and CHV referral outside of the local health facility. Whereas the broader contextual factors that affected CHV performance included: demand for material or financial support; perceived corruption in community programmes; and neighbourhood insecurity. These findings suggest that CHVs working in UIS in Kenya face a myriad of challenges that impact their wellbeing and performance. Therefore, to enhance CHVs' well-being and improve their performance, the following should be considered: adequate and timely remuneration for CHVs, appropriate holistic training, adequate supportive supervision, and ensuring a satisfactory supply of resources and supplies. Additionally, at the facility level, healthcare workers should be trained on appropriate and respectful relations with both the community and the CHVs, clarity of roles and scope of work, ensure availability of services, and safeguard against corrupt practices in public health facilities. Lastly, there's a need for improved and adequate security measures at the community level, to ensure safety of CHVs as they undertake their roles.
Collapse
Affiliation(s)
- Michael O. Ogutu
- Health Systems & Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Eric Kamui
- Health Systems & Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kui Muraya
- Health Systems & Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Population Council, Nairobi, Kenya
| |
Collapse
|
9
|
Aron MB, Ndambo MK, Munyaneza F, Mulwafu M, Makungwa H, Nhlema B, Connolly E. A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi. HUMAN RESOURCES FOR HEALTH 2023; 21:51. [PMID: 37365561 DOI: 10.1186/s12960-023-00839-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi. METHODS We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks. RESULTS We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05). CONCLUSION This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.
Collapse
Affiliation(s)
- Moses Banda Aron
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi.
| | | | | | - Manuel Mulwafu
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | - Henry Makungwa
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | | | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, United States of America
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, United States of America
| |
Collapse
|
10
|
Mabetha D, Ojewola T, van der Merwe M, Mabika R, Goosen G, Sigudla J, Hove J, Witter S, D'Ambruoso L. Realising radical potential: building community power in primary health care through Participatory Action Research. Int J Equity Health 2023; 22:94. [PMID: 37198678 DOI: 10.1186/s12939-023-01894-7] [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: 11/19/2022] [Accepted: 04/14/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component. METHODS Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks. RESULTS Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district. CONCLUSIONS Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.
Collapse
Affiliation(s)
- Denny Mabetha
- Cochrane South Africa, South African Medical Research Council (MRC), Cape Town, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
| | - Temitope Ojewola
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- Health Education England, Northwest, Manchester, England, UK
| | - Maria van der Merwe
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
- Maria Van Der Merwe Consulting, White River, South Africa
| | | | | | - Jerry Sigudla
- Mpumalanga Department of Health, Mbombela, South Africa
| | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, UK
| | - Lucia D'Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, and Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland, UK.
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, UK.
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Public Health, National Health Service (NHS) Grampian, Aberdeen, Scotland, UK.
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa.
| |
Collapse
|
11
|
Bolton P, West J, Whitney C, Jordans MJ, Bass J, Thornicroft G, Murray L, Snider L, Eaton J, Collins PY, Ventevogel P, Smith S, Stein DJ, Petersen I, Silove D, Ugo V, Mahoney J, el Chammay R, Contreras C, Eustache E, Koyiet P, Wondimu EH, Upadhaya N, Raviola G. Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care. Glob Ment Health (Camb) 2023; 10:e16. [PMID: 37854402 PMCID: PMC10579648 DOI: 10.1017/gmh.2023.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 03/02/2023] Open
Abstract
This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization's Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.
Collapse
Affiliation(s)
- Paul Bolton
- United States Agency for International Development, Washington, DC, USA
| | - Joyce West
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Mark J.D. Jordans
- King’s College London, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, London, UK
| | - Judith Bass
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Graham Thornicroft
- King’s College London, Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Laura Murray
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Pamela Y. Collins
- Department of Psychiatry and Behavioral Sciences and Department of Global Health, UW Consortium for Global Mental Health and International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, USA
| | - Peter Ventevogel
- United Nations High Commissioner for Refugees, Public Health Section, Geneva, Switzerland
| | - Stephanie Smith
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, USA
| | - Dan J. Stein
- SAMRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry & Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | | | | | - Victor Ugo
- The MHPSS Collaborative, Copenhagen, Denmark
| | - John Mahoney
- Centre for Mental Health, University of Melbourne VCCC, School of Population and Global Health, Global and Cultural Mental Health Unit, Parkville, VIC, Australia
| | - Rabih el Chammay
- National Mental Health Programme, Ministry of Public Health, Lebanese Government, Beirut, Lebanon
| | | | - Eddy Eustache
- Zanmi Lasante (Partners In Health), Mirebalais, Haiti
| | | | | | | | - Giuseppe Raviola
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Jenkins CR, Rutledge M, Hudson L, Vanderford NL, Schoenberg NE. Examining Psychological and Knowledge Barriers to Colorectal Cancer Screening in Rural Appalachian Kentucky. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:325-332. [PMID: 34984660 PMCID: PMC10433712 DOI: 10.1007/s13187-021-02120-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
While recent rates of colorectal cancer (CRC) screening have improved in Appalachian Kentucky due to public health efforts, they remain lower compared to both KY as a whole, and the USA. Suboptimal screening rates represent a missed opportunity to engage in early detection and prevention. The purpose of this study is to determine the impact that lack of knowledge has on psychological barriers (e.g., fear and embarrassment) to CRC screening as well as the potential effect of a psychosocial intervention to reduce these barriers. Participants were recruited through faith-based organizations and other community sites. After randomizing participants to either an early or delayed group, a faith-based group education and motivational interviewing intervention was administered. Existing and pilot tested instruments were used to assess knowledge and potential psychological barriers. Data were analyzed using paired t tests and linear regression. We hypothesized that (1) psychological barriers are associated with inadequate knowledge and (2) the intervention, by improving knowledge, could reduce these barriers and increase screening rates. There was a small but significant reduction in psychological barriers (-0.11, p value = 0.015) and moderate increases in CRC knowledge scores (+0.17, p value = 0.06). There was no evidence that the intervention affected these measures (+0.10, p value = 0.58). The relationship between lower barrier scores and increased knowledge was significant at follow up (-0.05, 95% CI (-0.09, -0.00)). An increase in CRC knowledge was correlated with a small but significant decrease in psychological barriers, although there was no evidence that these changes were associated with one another. Future cognitive-based interventions may be effective in increasing CRC knowledge and reducing barriers, but new intervention approaches should be considered.
Collapse
Affiliation(s)
- Caroline R Jenkins
- University of Kentucky College of Medicine, 800 Rose Street, Lexington, KY, 40506, USA.
| | | | - Lauren Hudson
- Markey Cancer Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA
| | - Nathan L Vanderford
- Markey Cancer Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA
- Department of Toxicology and Cancer Biology, College of Medicine, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA
| | - Nancy E Schoenberg
- Department of Behavioral Science, University of Kentucky, Lexington, KY, 40508, USA
- Center for Health Equity Transformation, University of Kentucky, 372 Healthy Kentucky Research Building, Lexington, KY, 40536-0086, USA
| |
Collapse
|
13
|
Mahmud I, Siddiqua S, Akhter I, Sarker M, Theobald S, Rashid SF. Factors affecting motivation of close-to-community sexual and reproductive health workers in low-income urban settlements in Bangladesh: A qualitative study. PLoS One 2023; 18:e0279110. [PMID: 36638097 PMCID: PMC9838845 DOI: 10.1371/journal.pone.0279110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/29/2022] [Indexed: 01/14/2023] Open
Abstract
Close-to-community (CTC) health workers play a vital role in providing sexual and reproductive health services in low-income urban settlements in Bangladesh. Retention of CTC health workers is a challenge, and work motivation plays a vital role in this regard. Here, we explored the factors which affect their work motivation. We conducted 22 in-depth interviews in two phases with purposively selected CTC health workers operating in low-income urban settlements in Dhaka, Bangladesh. We analyzed our data using the framework technique which involved identifying, abstracting, charting, and matching themes across the interviews following the two-factor theory on work motivation suggested by Herzberg and colleagues. Our results suggest that factors affecting CTC sexual and reproductive health workers' work motivation include both extrinsic and intrinsic factors. Extrinsic or hygiene factors include financial incentives, job security, community attitude, relationship with the stakeholders, supportive and regular supervision, monitoring, and physical safety and security. While, the intrinsic factors or motivators are the perceived quality of the services provided, witnessing the positive impact of the work in the community, the opportunity to serve vulnerable clients, professional development opportunities, recognition, and clients' compliance. In the context of a high unemployment rate, people might take a CTC health worker's job temporarily to earn a living or to use it as a pathway move to more secure employment. To maintain and improve the work motivation of the CTC sexual and reproductive health workers serving in low-income urban settlements, organizations should provide adequate financial incentives, job security, and professional development opportunities in addition to supportive and regular supervision.
Collapse
Affiliation(s)
- Ilias Mahmud
- Department of Public Health, College of Public Health and Health Informatics, Qassim University, Al Bukairiyah, Saudi Arabia
- BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
- * E-mail:
| | - Sumona Siddiqua
- BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Irin Akhter
- BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Malabika Sarker
- BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
- Heidleberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Sabina Faiz Rashid
- BRAC James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| |
Collapse
|
14
|
McCarville EE, Martin MA, Pratap PL, Pinsker E, Seweryn SM, Peters KE. Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study. BMC Health Serv Res 2022; 22:1587. [PMID: 36575412 PMCID: PMC9793519 DOI: 10.1186/s12913-022-08723-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/23/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Community health workers (CHW) have grown in prominence within the healthcare sector, yet there is no clear consensus regarding a CHW's role, purpose, and value within health systems. This lack of consensus has the potential to affect how CHWs are perceived, utilized, and ultimately integrated within the healthcare sector. This research examines clinical care teams that currently employ CHWs to (1) understand how members of the care team perceive CHWs' purpose and value, and (2) consider how perceptions of CHWs are related to CHW integration within health care teams. METHODS Researchers conducted a qualitative descriptive multiple embedded case study at the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within UI Health that are currently employing CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. RESULTS In total, 6 sub-units were enrolled to participate, and 17 interviews were conducted with CHWs (n = 9), and administrators or health care providers (n = 8). Reported perceptions of CHWs were inconsistent across respondents. CHWs roles were not always understood, and the CHW's purpose and value was perceived differently by different members of the care team. Moreover, evaluation metrics did not always capture CHWs' value to the health care system. In some cases, care teams were more aligned around a shared understanding of the CHW's roles and purpose within the care team. When perceptions regarding CHWs were both positive and aligned, respondents reported higher levels of integration within the healthcare system. CONCLUSIONS Alignment in a care team's perception of a CHW's role, purpose, and value within the health system could play an important role in the integration of CHWs within healthcare teams.
Collapse
Affiliation(s)
- Erin E. McCarville
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, School of Public Health, 1603 W Taylor Street, Chicago, IL 60612 USA
| | - Molly A. Martin
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, Institute for Health Research and Policy, 1747 West Roosevelt Road, Chicago, IL 60608 USA
| | - Preethi Lakshmi Pratap
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, School of Public Health, 1603 W Taylor Street, Chicago, IL 60612 USA
| | - Eve Pinsker
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, School of Public Health, 1603 W Taylor Street, Chicago, IL 60612 USA
| | - Steven M. Seweryn
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, School of Public Health, 1603 W Taylor Street, Chicago, IL 60612 USA
| | - Karen E. Peters
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, Institute for Health Research and Policy, 1747 West Roosevelt Road, Chicago, IL 60608 USA
| |
Collapse
|
15
|
Mupara LM, Mogaka JJO, Brieger WR, Tsoka-Gwegweni JM. Health systems strengthening through policy-level integration of community health worker programs into national health systems for improved health outcomes - scorecard metrics validation: A bifactor structural equation model approach. Front Public Health 2022; 10:907451. [PMID: 36620294 PMCID: PMC9822652 DOI: 10.3389/fpubh.2022.907451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
Background Subsequent to the demonstrated potential of community health workers (CHWs) in strengthening health systems to improve health outcomes, recent literature has defined context and guidelines for integrating CHW programs into mainstream health systems. However, quantitative measures for assessing the extent of CHW program integration into national health systems need to be developed. The purpose of this study was to validate a newly developed scale, Community Health Worker Program Integration Scorecard Metrics (CHWP-ISM), for assessing the degree of integration of CHW programs into national health systems in Sub-Saharan Africa (SSA). Methods Data obtained through a pilot study involving a purposively selected sample of 41 participants selected from populations involved in CHW programs work in selected countries of SSA formed the basis of a 31-item bifactor model. Data were collected between June and December 2019. By applying a latent variable approach implemented with structural equation modeling, data analysis was mainly done using the R statistical environment, applying factor analysis procedures. Results Dimensionality, construct validity, and the CHWP-ISM scale's internal consistency were assessed. Confirmatory factor analysis of the CHW-ISM bifactor model supported a co-occurring CHW integration general factor and six unique domain-specific factors. Both the comparative fit index (CFI) and Tucker-Lewis Index (TLI) fit indices were above 0.9, while the root mean square of the residuals (RMSR) was 0.02. Cronbach's alpha (α), Guttman 6 (Lambda 6), and Omega total (ωt) were above 0.8, indicating good scale reliability. Conclusion Statistical significance of the bifactor model suggests that CHW integration has to be examined using factors that reflect a single common underlying integration construct, as well as factors that reflect unique variances for the identified six subject-specific domains. The validated CHWP-ISM could be useful to inform policy advisers, health systems, donors, non-governmental organizations, and other CHW program stakeholders with guidance on how to quantitatively assess the integration status of different components of CHW programs into respective critical functions of the health system. Improved integration could increase CHW program functionality, which could in turn strengthen the healthcare systems to improve health outcomes in the region.
Collapse
Affiliation(s)
- Lucia Mungapeyi Mupara
- Department of Public Health Medicine, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
| | - John Jules O. Mogaka
- Department of Public Health Medicine, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
| | - William R. Brieger
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MA, United States
| | - Joyce M. Tsoka-Gwegweni
- Department of Public Health Medicine, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
- Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| |
Collapse
|
16
|
Lar L, Stewart M, Isiyaku S, Dean L, Ozano K, Mpyet C, Theobald S. Does inter-border conflict influence the views of task sharing among community health volunteers in Nigeria? A qualitative study. Confl Health 2022; 16:43. [PMID: 35871004 PMCID: PMC9308912 DOI: 10.1186/s13031-022-00472-y] [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: 11/24/2021] [Accepted: 06/27/2022] [Indexed: 01/17/2023] Open
Abstract
Background Volunteer community health workers are increasingly being engaged in Nigeria, through the World Health Organization’s task sharing strategy. This strategy aims to address gaps in human resources for health, including inequitable distribution of health workers. Recent conflicts in rural and fragile border communities in northcentral Nigeria create challenges for volunteer community health workers to meet their community's increasing health needs. This study aimed to explore the perception of volunteers involved in task sharing to understand factors affecting performance and delivery in such contexts. Methods This was a qualitative study conducted in fragile border communities in north central Nigeria. Eighteen audio recorded, semi-structured interviews with volunteers and supervisors were performed. Their perceptions on how task sharing and allocation of tasks affect performance and delivery were elucidated. The transactional social framework was applied during the thematic analysis process to generate an explanatory account of the research data, which was analysed using NVivo software. Results Promotive and preventive tasks were shared among the predominantly agrarian respondents. There was a structured task allocation process that linked the community with the health system and mainly cordial relationships were in place. However, there were barriers related to ethnoreligious crises and current conflict, timing of task allocations, gender inequities in volunteerism, shortage of commodities, inadequate incentives, dwindling community support and negative attitudes of some volunteers. Conclusion The perception of task sharing was mainly positive, despite the challenges, especially the current conflict. In this fragile context, reconsideration of non-seasonal task allocations within improved community-driven selection and security systems should be encouraged. Supportive supervision and providing adequate and timely renumeration will also be beneficial in this fragile setting.
Collapse
|
17
|
Yahner M, Muriuki A, Mangieri A, Nitu SNA, Shafinaz S, Sarriot E. Designing for Impact and Institutionalization: Applying Systems Thinking to Sustainable Postpartum Family Planning Approaches for First-Time Mothers in Bangladesh. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2200023. [PMID: 36316131 PMCID: PMC9622282 DOI: 10.9745/ghsp-d-22-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/13/2022] [Indexed: 12/04/2022]
Abstract
Integrated service delivery approaches have shown promise to increase use of services including postpartum family planning (PPFP) by young, first-time mothers (FTMs) but have proven challenging to scale and institutionalize. Integration adds complexity, requiring careful assessment of effects on a range of key system functions from demand creation and service delivery to oversight and governance. Through an innovative design process, we selected approaches to increase FTMs' PPFP use through existing health systems. We generated programmatic options and then sought to select approaches based on (1) potential impact on FTMs' PPFP uptake and (2) potential to institutionalize in the health system. The latter represented an innovation in addressing management systems' drivers of scalability and sustainability; to accomplish it, we developed a participatory design process to assess the potential of an approach to be institutionalized in a specific context.We adapted a management systems theory, the Viable System Model (VSM), which presents 5 essential organizational functions and the relations required between them to improve the viability (performance and institutionalization) of organizational systems. Drawing from the VSM, we developed a process for reviewing the effects of proposed approaches on provider workload, client flow, infrastructure, revisions to guidelines and job descriptions, coordination and management, and information systems. The VSM provided a structure to identify potential displacement of capacity in the health system and mitigate often neglected organizational challenges that compromise institutionalization. The process informed the elimination of approaches with potential for impact but that had deal-breakers to institutionalization, such as increased workload or shifted job descriptions, in the Bangladeshi context. For the selected approaches, consideration of systems elements fostered discussion of expected risks to institutionalization, highlighting needed mitigation efforts and monitoring during implementation.
Collapse
Affiliation(s)
| | - Angela Muriuki
- Independent consultant; formerly of Save the Children Kenya, Nairobi, Kenya
| | | | | | - Shumona Shafinaz
- Independent consultant; formerly of Save the Children Bangladesh, Dhaka, Bangladesh
| | - Eric Sarriot
- Gavi, the Vaccine Alliance, Geneva, Switzerland; formerly of Save the Children US, Washington, DC, USA
| |
Collapse
|
18
|
Khumalo GE, Lutge E, Mashamba-Thompson TP. Exploring how outreach team leaders perceive community health workers' experiences of providing HIV services in KwaZulu-Natal, South Africa. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2022; 21:239-250. [PMID: 36102053 DOI: 10.2989/16085906.2022.2060841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 06/15/2023]
Abstract
Objectives: In 2018, the KwaZulu-Natal Department of Health launched the ward-based primary health care outreach teams policy framework which sought to expand the community health worker (CHW) programme's provision of longitudinal patient support, including human immunodeficiency virus (HIV) services in communities. This study sought to explore the perceptions of outreach team leaders who supervise CHWs on their experiences of providing HIV services in the province.Study design: This was a qualitative, phenomenology study.Methods: Convenience sampling was done to select one outreach team leader from each of the 11 KwaZulu-Natal health districts to be interviewed using an interview guide. Thematic analysis, guided by the Ritchie and Spencer framework analysis, was used to analyse the data.Results: The challenges faced by CHWs in delivering HIV services were: the absence of individuals when CHWs visited their homes, self-HIV stigma, rejection of CHWs' HIV services due to traditional beliefs, CHW shortages, lack of other resources, low levels of CWH education and a lack of training. On the other hand, the provision of HIV services was fascilitated by: supportive supervision, training, having cell phones and having a positive attitude towards providing HIV services by CHWs that were HIV-positive.Conclusion: The CHWs in KwaZulu-Natal face more challenges than enablers in the provision of HIV services. The delegation of HIV services to CHWs should be aligned with their holistic empowerment by eliminating barriers to the provision of HIV services.
Collapse
Affiliation(s)
- Gugulethu E Khumalo
- Public Health Medicine, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
- Health Research & Knowledge Management Unit, KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Elizabeth Lutge
- Public Health Medicine, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
- Health Research & Knowledge Management Unit, KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Tivani P Mashamba-Thompson
- Public Health Medicine, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
- Faculty of Health Sciences, University of Pretoria, Prinshof Campus, Pretoria, South Africa
| |
Collapse
|
19
|
Ludwick T, Endriyas M, Morgan A, Kane S, Kelaher M, McPake B. Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia's Family Health Teams. Int J Health Policy Manag 2022; 11:1459-1471. [PMID: 34273919 PMCID: PMC9808330 DOI: 10.34172/ijhpm.2021.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/27/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia's family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities. METHODS Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and system-level factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains. RESULTS Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally-driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators. CONCLUSION Lessons from Ethiopia's challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.
Collapse
Affiliation(s)
- Teralynn Ludwick
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Misganu Endriyas
- Health Research and Technology Transfer Office, SNNPR Regional Health Bureau, Hawassa, Ethiopia
| | - Alison Morgan
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Margaret Kelaher
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
20
|
Conceptualising the Factors Influencing Community Health Workers’ Preparedness for ICT Implementation: A Systematised Scoping Review. SUSTAINABILITY 2022. [DOI: 10.3390/su14148930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Background: Globally, community health workers (CHW) are increasingly viewed as an integral part of the health system as opposed to simply being an extension of it. Given this view, most low- or middle-income countries (LMICs) have refocused their efforts on reorganising CHW initiatives to maximise their impact. The ongoing endeavours to augment the practice of community health workers using technological solutions are characterised by as many challenges as opportunities. In low- and middle-income countries, including South Africa, information and communication technology (ICT) has become a promising development in the enhancement of the equitable coverage of health services by community health workers. However, there has not been a wide-scale implementation and adoption of ICT; most technology initiatives fail to scale up during the implementation stage, which is attributable to human and context-related factors. Although there has been an effort to develop solutions to address ICT infrastructure and technical barriers, conceptualising an evidence-based understanding of the contextual and user-related factors that influence the efficacy of technology adoption by CHWs within their multidimensional system remains critical. Objective: The purpose of the study is to conceptualise the social factors to consider when implementing a bespoke ICT solution suited to the specific demands of CHWs in primary healthcare in developing contexts, with a particular focus on the South African context. Methodology: The methodology involves synthesizing, extracting, and consolidating the findings of a systematised scoping review into concepts and factors. The review adapts Arksey and O’Malley’s scoping review approach to the study and incorporates 59 relevant articles. Results: Although the knowledge base on CHWs is extensive, there is a considerable gap in addressing structural challenges within the community system, which contributes significantly to the overall performance of CHW programs. Factors promoting policy adaptations, common practice within the health system, CHW competencies, a community’s development in terms of knowledge and economic advancement, safety and security, the environment, and the socio-cultural context all play a significant role in facilitating or impeding the success of health interventions from the individual to the national level. Conclusions: Within several practical limitations, the study shows that despite the efforts of various developing countries to promote technology adoption, the barriers to ICT adoption outweigh the benefits gained in developing countries. The paper argues that addressing these challenges before and during implementation is critical. The authors conclude with some essential concerns about assisting CHWs towards realising the desired health outcomes through ICT.
Collapse
|
21
|
Babalola O, Goudge J, Levin J, Brown C, Griffiths F. Assessing the Utility of a Quality-of-Care Assessment Tool Used in Assessing Comprehensive Care Services Provided by Community Health Workers in South Africa. Front Public Health 2022; 10:868252. [PMID: 35651863 PMCID: PMC9149253 DOI: 10.3389/fpubh.2022.868252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Few studies exist on the tools for assessing quality-of-care of community health worker (CHW) who provide comprehensive care, and for available tools, evidence on the utility is scanty. We aimed to assess the utility components of a previously-reported quality-of-care assessment tool developed for summative assessment in South Africa. Methods In two provinces, we used ratings by 21 CHWs and three team leaders in two primary health care facilities per province regarding whether the tool covered everything that happens during their household visits and whether they were happy to be assessed using the tool (acceptability and face validity), to derive agreement index (≥85%, otherwise the tool had to be revised). A panel of six experts quantitatively validated 11 items of the tool (content validity). Content validity index (CVI), of individual items (I-CVI) or entire scale (S-CVI), should be >80% (excellent). For the inter-rater reliability (IRR), we determined agreement between paired observers' assigned quality-of-care messages and communication scores during 18 CHW household visits (nine households per site). Bland and Altman plots and multilevel model analysis, for clustered data, were used to assess IRR. Results In all four CHW and team leader sites, agreement index was ≥85%, except for whether they were happy to be assessed using the tool, where it was <85% in one facility. The I-CVI of the 11 items in the tool ranged between 0.83 and 1.00. For the S-CVI, all six experts agreed on relevancy (universal agreement) in eight of 11 items (0.72) whereas the average of I-CVIs, was 0.95. The Bland-Altman plot limit of agreements between paired observes were −0.18 to 0.44 and −0.30 to 0.44 (messages score); and −0.22 to 0.45 and −0.28 to 0.40 (communication score). Multilevel modeling revealed an estimated reliability of 0.77 (messages score) and 0.14 (communication score). Conclusion The quality-of-care assessment tool has a high face and content validity. IRR was substantial for quality-of-care messages but not for communication score. This suggests that the tool may only be useful in the formative assessment of CHWs. Such assessment can provide the basis for reflection and discussion on CHW performance and lead to change.
Collapse
Affiliation(s)
- Olukemi Babalola
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Goudge
- Centre for Health Policy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Levin
- Department of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celia Brown
- Division of Health Sciences, University of Warwick, Warwick Medical School, Coventry, United Kingdom
| | - Frances Griffiths
- Division of Health Sciences, University of Warwick, Warwick Medical School, Coventry, United Kingdom
| |
Collapse
|
22
|
Oliphant NP, Ray N, Curtis A, Musa E, Sesay M, Kandeh J, Kamara A, Hassen K, O'Connor S, Suehiro Y, Legesse H, Chimoun EFT, Jackson D, Doherty T. Optimising scale and deployment of community health workers in Sierra Leone: a geospatial analysis. BMJ Glob Health 2022; 7:bmjgh-2021-008141. [PMID: 35589152 PMCID: PMC9121426 DOI: 10.1136/bmjgh-2021-008141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/04/2022] [Indexed: 11/22/2022] Open
Abstract
Background Little is known about strategies for optimising the scale and deployment of community health workers (CHWs) to maximise geographic accessibility of primary healthcare services. Methods We used data from a national georeferenced census of CHWs and other spatial datasets in Sierra Leone to undertake a geospatial analysis exploring optimisation of the scale and deployment of CHWs, with the aim of informing implementation of current CHW policy and future plans of the Ministry of Health and Sanitation. Results The per cent of the population within 30 min walking to the nearest CHW with preservice training increased from 16.1% to 80.4% between 2000 and 2015. Contrary to current national policy, most of this increase occurred in areas within 3 km of a health facility where nearly two-thirds (64.5%) of CHWs were deployed. Ministry of Health and Sanitation-defined ‘easy-to-reach’ and ‘hard-to-reach’ areas, geographic areas that should be targeted for CHW deployment, were less well covered, with 19.2% and 34.6% of the population in 2015 beyond a 30 min walk to a CHW, respectively. Optimised CHW networks in these areas were more efficiently deployed than existing networks by 22.4%–71.9%, depending on targeting metric. Interpretations Our analysis supports the Ministry of Health and Sanitation plan to rightsize and retarget the CHW workforce. Other countries in sub-Saharan Africa interested in optimising the scale and deployment of their CHW workforce in the context of broader human resources for health and health sector planning may look to Sierra Leone as an exemplar model from which to learn.
Collapse
Affiliation(s)
- Nicholas Paul Oliphant
- University of the Western Cape, School of Public Health, Bellville, South Africa .,The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Nicolas Ray
- Geohealth Group, University of Geneva, Institute of Global Health, Geneva, Switzerland.,University of Geneva, Institute of Environmental Sciences, Geneva, Switzerland
| | - Andrew Curtis
- Geohealth Group, University of Geneva, Institute of Global Health, Geneva, Switzerland.,University of Geneva, Institute of Environmental Sciences, Geneva, Switzerland
| | - Elizabeth Musa
- CHW Hub, Directorate of Primary Health Care, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Momodu Sesay
- Directorate of Primary Health Care, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Joseph Kandeh
- Directorate of Primary Health Care, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Anitta Kamara
- National Malaria Control Program, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Kebir Hassen
- UNICEF Sierra Leone, Freetown, Sierra Leone.,UNICEF Sudan, Khartoum, Sudan
| | | | | | | | | | - Debra Jackson
- University of the Western Cape, School of Public Health, Bellville, South Africa.,London School of Hygiene and Tropical Medicine, Centre for Maternal Adolescent Reproductive and Child Health, London, UK
| | - Tanya Doherty
- University of the Western Cape, School of Public Health, Bellville, South Africa.,Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| |
Collapse
|
23
|
Harrison L, Kumwenda M, Nyirenda L, Chilongosi R, Corbett E, Hatzold K, Johnson C, Simwinga M, Desmond N, Taegtmeyer M. "You have a self-testing method that preserves privacy so how come you cannot give us treatment that does too?" Exploring the reasoning among young people about linkage to prevention, care and treatment after HIV self-testing in Southern Malawi. BMC Infect Dis 2022; 22:395. [PMID: 35449095 PMCID: PMC9026576 DOI: 10.1186/s12879-022-07231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Young people, aged 16-24, in southern Malawi have high uptake of HIV self-testing (HIVST) but low rates of linking to services following HIVST, especially in comparison, to older generations. The study aim is to explore the barriers and facilitators to linkage for HIV prevention and care following uptake of HIV self-testing among young Malawians. METHODS We used qualitative methods. Young people aged 16-24 who had received HIVST; community-based distribution agents (CBDAs) and health care workers from the linked facilities were purposively sampled from two villages in rural southern Malawi. RESULTS We conducted in-depth interviews with thirteen young people (9 female) and held four focus groups with 28 healthcare workers and CBDAs. Young people strongly felt the social consequences associated with inadvertent disclosure of HIV sero-status were a significant deterrent to linkage at their stage in life. They also felt communication on testing benefits and the referral process after testing was poor. In contrast, they valued encouragement from those they trusted, other's positive treatment experiences and having a "strength of mind". CBDAs were important facilitators for young people as they are able to foster a trusting relationship and had more understanding of the factors which prevented young people from linking following HIVST than the healthcare workers. Young people noted contextual barriers to linkage, for example, being seen on the road to the healthcare centre, but also societal gendered barriers. For example, young females and younger adolescents were less likely to have the financial independence to link to services whilst young males (aged 19-24) had the finances but lacked a supportive network to encourage linkage following testing. Overall, it was felt that the primary "responsibility" for linking to formal healthcare following self-testing is shouldered by the young person and not the healthcare system. CONCLUSIONS Young people are happy to self-test for HIV but faced barriers to link to services following a self-test. Potential interventions for improving linkage suggested by this analysis include the establishment of youth-friendly linkage services, enhanced lines of communication between young people and healthcare providers and prioritising linkage for future interventions when targeting young people following HIVST.
Collapse
Affiliation(s)
- Lisa Harrison
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Moses Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Lot Nyirenda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Richard Chilongosi
- Department of HIV Prevention, Population Services International, Blantyre, Malawi
| | - Elizabeth Corbett
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Cheryl Johnson
- Department of Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | | | - Nicola Desmond
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| |
Collapse
|
24
|
Gebremeskel AT, Omonaiye O, Yaya S. Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review. BMJ Glob Health 2022; 7:bmjgh-2021-008162. [PMID: 35393287 PMCID: PMC8991040 DOI: 10.1136/bmjgh-2021-008162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/26/2022] [Indexed: 12/29/2022] Open
Abstract
Background Countries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile health systems. Community health workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in improving maternal and child health (MCH). However, evidence is limited on multilevel determinants of an effective CHWs programme using CHWs’ perspective. The objective of this systematic review is to examine perceived barriers to and enablers of different levels of the determinants of the CHWs’ engagement to enhance MCH equity and a resilient community health system in SSA. Methods We systematically conducted a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Qualitative studies that presented information on perceived barriers to and facilitators of effectiveness of CHWs in SSA were eligible for inclusion. Quality appraisal was conducted according to the Critical Appraisal Skills Programme qualitative study checklist. We used a framework analysis to identify key findings. Findings From the database search, 1561 articles were identified. Nine articles met the inclusion criteria and were included in the final review. Using socio-ecological framework, we identified the determinants of CHWs’ effectiveness at 4 levels: individual/CHWs, interpersonal, community and health system logistics. Under each level, we identified themes of perceived barriers such as competency gaps, lack of collaboration, fragmentation of empowerment programmes. In terms of facilitators, we identified themes such as CHW empowerment, interpersonal effectiveness, community trust, integration of CHWs into health systems and technology. Conclusion Evidence from this review revealed that effectiveness of CHW/MCH programme is determined by multilevel contextual factors. The socio-ecological framework can provide a lens of understanding diverse context that impedes or enhances CHWs’ engagement and effectiveness at different levels. Hence, there is a need for health programme policy makers and practitioners to adopt a multilevel CHW/MCH programme guided by the socio-ecological framework to transform CHW programmes. The framework can help to address the barriers and scale up the facilitators to ensuring MCH equity and a resilient community health system in SSA.
Collapse
Affiliation(s)
- Akalewold T Gebremeskel
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.,School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
| | - Olumuyiwa Omonaiye
- School of Health and Social Development, Institute for Health Transformation, Deakin University, Melbourne-Burwood Campus, Burwood, Victoria, Australia
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada .,The George Institute for Global Health, Imperial College London, London, UK
| |
Collapse
|
25
|
Baratieri T, Lentsck MH, Falavina LP, Soares LG, Prezotto KH, Pitilin ÉDB. [Longitudinal care: factors associated with adherence to postpartum follow-up according to data from PMAQ-AB]. CAD SAUDE PUBLICA 2022; 38:e00103221. [PMID: 35293537 DOI: 10.1590/0102-311x00103221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/08/2021] [Indexed: 11/21/2022] Open
Abstract
The aim was to identify factors of longitudinal care associated with women´s adherence to postpartum consultation in Brazil. This was a cross-sectional study of data from 19,177 postpartum women who participated in the external assessment of the third cycle of the Brazilian National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB), 2017. The dependent variable was postpartum consultation, and the independent variables, grouped hierarchically, were sociodemographic and economic at the distal level and issues analogous to longitudinal care at the proximal level. Multiple logistic regression analysis was performed with hierarchical entry of variables, where sociodemographic and economic variables were used to adjust the model. The results showed that 53% of women had undergone postpartum follow-up. The odds of adherence to postpartum follow-up were higher in women who received a home visit by a community health agents in the first week after childbirth (OR = 4.81), those with seven or more prenatal consultations (OR = 2.74), those who had sought care at the health unit in question (OR = 1.21), and those who had been seen by the same physician (OR = 1.14). In conclusion, the proportion of postpartum consultations was low (53%), and adherence to postpartum follow-up was higher when women received visits by community health agents, were accompanied by the same physician, had regular prenatal care, and had a specific healthcare unit as their regular source of care. Consistent longitudinal care was identified as an attribute of primary care that should be strengthened to improve postpartum care.
Collapse
|
26
|
Ndambo MK, Munyaneza F, Aron MB, Nhlema B, Connolly E. Qualitative assessment of community health workers' perspective on their motivation in community-based primary health care in rural Malawi. BMC Health Serv Res 2022; 22:179. [PMID: 35148772 PMCID: PMC8840069 DOI: 10.1186/s12913-022-07558-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities. METHODS We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March-April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose. RESULTS Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs. CONCLUSION This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can focus on enhancing motivational factors found in this study to improve the CHWs' experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.
Collapse
Affiliation(s)
| | - Fabien Munyaneza
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
| | - Moses Banda Aron
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
| | - Basimenye Nhlema
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
| | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi.,Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, USA
| |
Collapse
|
27
|
Pollard R, Kennedy CE, Hutton HE, Mulamba J, Mbabali I, Anok A, Nakyanjo N, Chang LW, Amico KR. HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda. AIDS Behav 2022; 26:375-384. [PMID: 34327597 PMCID: PMC8800949 DOI: 10.1007/s10461-021-03391-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 02/03/2023]
Abstract
A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the Rakai Health Sciences Program implemented a CHW HIV intervention called Health Scouts. The situated Information, Motivation, and Behavioral Skills (sIMB) framework informed the design and a qualitative evaluation of the intervention. We interviewed 51 intervention clients and coded transcripts informed by sIMB framework dimensions. Clients reported that Health Scouts provided information about HIV prevention and treatment behaviors and helped them manage personal and social motivations to carry out health-promoting behavior. Prominent barriers which moved clients away from behavior change included daily pill burdens, anticipated stigma, serostatus disclosure, substance use at social gatherings, and anticipated reactions of partners. Our study adds to the evidence establishing CHWs as facilitators of behavior change, positioned to offer supportive encouragement and navigate contextualized circumstances.
Collapse
Affiliation(s)
- Rose Pollard
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., 4th Floor, Baltimore, MD, 21205, USA.
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Rakai Health Sciences Program, Rakai, Uganda
| | - Heidi E Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | - Aggrey Anok
- Rakai Health Sciences Program, Rakai, Uganda
| | | | - Larry W Chang
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., 4th Floor, Baltimore, MD, 21205, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Rakai Health Sciences Program, Rakai, Uganda
| | - K Rivet Amico
- Department of Health Behavior Health Education, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
28
|
Rodriguez NM, Ruiz Y, Meredith AH, Kimiecik C, Adeoye-Olatunde OA, Kimera LF, Gonzalvo JD. Indiana community health workers: challenges and opportunities for workforce development. BMC Health Serv Res 2022; 22:117. [PMID: 35086545 PMCID: PMC8792135 DOI: 10.1186/s12913-022-07469-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An interest in, and the need for, Community Health Workers (CHWs) in the United States is growing exponentially. CHWs possess a unique ability to relate to and build trust with communities in order to improve clinical outcomes, while building individual and community capacity. Given their critical role in addressing social determinants of health, expanding the CHW workforce is crucial. However, creating CHW jobs, facilitating training and certification, and establishing sustainable financing models to support this workforce has been challenging. METHODS A mixed-methods study consisting of an online survey and focus group discussions assessed the strengths, practices, and challenges to CHW workforce sustainability and expansion in the state of Indiana, including perspectives from both CHWs and employers. RESULTS Across 8 topics, mixed data analysis revealed 28 findings that were both complementary and unique across focus group and survey results. Results highlighted CHW skills and attributes, illustrated the recruitment and hiring process, and provided insight into measuring outcomes and outputs. Findings also indicated a need to build position validation, professional development, and billing and reimbursement capacity. CONCLUSION Building and sustaining the CHW workforce will require creating an evidence base of roles and impact, increasing awareness of existing reimbursement mechanisms, and sharing best practices across employer organizations to promote optimal recruitment, training, supervision, career development, and funding strategies.
Collapse
Affiliation(s)
- Natalia M Rodriguez
- College of Health and Human Sciences, Department of Public Health, Purdue University, 812 W. State Street, West Lafayette, IN, 47907, USA
| | - Yumary Ruiz
- College of Health and Human Sciences, Department of Public Health, Purdue University, 812 W. State Street, West Lafayette, IN, 47907, USA
| | - Ashley H Meredith
- College of Pharmacy, Department of Pharmacy Practice, Purdue University Center for Health Equity and Innovation, 640 Eskenazi Ave, Fifth Third Bank FOB, 3rd Floor, Indianapolis, IN, 46202, USA
| | - Carlyn Kimiecik
- College of Health and Human Sciences, Department of Public Health, Purdue University, 812 W. State Street, West Lafayette, IN, 47907, USA
| | - Omolola A Adeoye-Olatunde
- College of Pharmacy, Department of Pharmacy Practice, Purdue University Center for Health Equity and Innovation, 640 Eskenazi Ave, Fifth Third Bank FOB, 3rd Floor, Indianapolis, IN, 46202, USA
| | - Lynnet Francesca Kimera
- College of Pharmacy, Department of Pharmacy Practice, Purdue University Center for Health Equity and Innovation, 640 Eskenazi Ave, Fifth Third Bank FOB, 3rd Floor, Indianapolis, IN, 46202, USA
| | - Jasmine D Gonzalvo
- College of Pharmacy, Department of Pharmacy Practice, Purdue University Center for Health Equity and Innovation, 640 Eskenazi Ave, Fifth Third Bank FOB, 3rd Floor, Indianapolis, IN, 46202, USA.
| |
Collapse
|
29
|
Musoke D, Nyashanu M, Bugembe H, Lubega GB, O’Donovan J, Halage AA, Gibson L. Contested notions of challenges affecting Community Health Workers in low- and middle-income countries informed by the Silences Framework. HUMAN RESOURCES FOR HEALTH 2022; 20:4. [PMID: 34991590 PMCID: PMC8734299 DOI: 10.1186/s12960-021-00701-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/14/2021] [Indexed: 05/03/2023]
Abstract
Despite increasing evidence of the challenges affecting Community Health Workers (CHWs) such as those related to training, supportive supervision and remuneration, there is a need to explore concerns and challenges from the perspective of CHWs themselves. This commentary highlights some of the contested and unexplored notions of challenges affecting CHWs in low- and middle-income countries (LMICs) informed by the Silences Framework. This framework defines experiences that are under-explored, misunderstood or difficult to share because of the often invisible power relations within communities, but also in setting the research agenda. These challenges include the heavy workload imposed by several stakeholders, dealing with religious and cultural practices, and gendered barriers of care. The workload of CHWs is a major source of stress and anxiety as they have to balance both government and other stakeholders' agendas to deliver interventions with their own need to provide for their families for those whose work is unpaid. The tensions of CHWs carrying out their work among members of the community whose religious or cultural beliefs are different from theirs also needs to be considered. Gender issues are an impediment to the work of CHWs, particularly with community members of the opposite sex around sensitive health issues. Lastly, CHWs have found themselves victims of domestic suspicion while fulfilling their duties in communities, such as when seen having conversations with spouses of other individuals in the community. Solutions to these challenges need to be co-produced with CHWs to both to strengthen their relationship with the communities they serve and shape more sustainable interventions for delivery of healthcare in LMICs.
Collapse
Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mathew Nyashanu
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | | | - Grace Biyinzika Lubega
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Abdullah Ali Halage
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
| |
Collapse
|
30
|
Oliphant NP, Sy Z, Koné B, Berthé M, Beebe M, Samake M, Diabaté M, Tounkara S, Diarra B, Diarra AB, Diawara CH, Yakimova T, Florisse S, Jackson D, Ray N, Doherty T. Improving the efficiency of scale-up and deployment of community health workers in Mali: A geospatial analysis. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000626. [PMID: 36962591 PMCID: PMC10021816 DOI: 10.1371/journal.pgph.0000626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 11/06/2022]
Abstract
Optimising the scale and deployment of community health workers (CHWs) is important for maximizing geographical accessibility of integrated primary health care (PHC) services. Yet little is known about approaches for doing so. We used geospatial analysis to model optimised scale-up and deployment of CHWs in Mali, to inform strategic and operational planning by the Ministry of Health and Social Development. Accessibility catchments were modelled based on travel time, accounting for barriers to movement. We compared geographic coverage of the estimated population, under-five deaths, and plasmodium falciparum (Pf) malaria cases across different hypothetical optimised CHW networks and identified surpluses and deficits of CHWs compared to the existing CHW network. A network of 15 843 CHW, if optimally deployed, would ensure that 77.3% of the population beyond 5 km of the CSCom (community health centre) and CSRef (referral health facility) network would be within a 30-minute walk of a CHW. The same network would cover an estimated 59.5% of U5 deaths and 58.5% of Pf malaria cases. As an intermediary step, an optimised network of 4 500 CHW, primarily filling deficits of CHW in the regions of Kayes, Koulikoro, Sikasso, and Ségou would ensure geographic coverage for 31.3% of the estimated population. There were no important differences in geographic coverage percentage when prioritizing CHW scale-up and deployment based on the estimated population, U5 deaths, or Pf malaria cases. Our geospatial analysis provides useful information to policymakers and planners in Mali for optimising the scale-up and deployment of CHW and, in turn, for maximizing the value-for-money of resources of investment in CHWs in the context of the country's health sector reform. Countries with similar interests in optimising the scale and deployment of their CHW workforce may look to Mali as an exemplar model from which to learn.
Collapse
Affiliation(s)
- Nicholas P Oliphant
- University of the Western Cape, School of Public Health, Bellville, Republic of South Africa
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Zeynabou Sy
- Faculty of Medicine, GeoHealth group, Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Brehima Koné
- Ministère de la Santé et du Développement Social du Mali, Direction Générale de la Santé et de l'Hygiène Publique, Bamako, Mali
| | - Mohamed Berthé
- Ministère de la Santé et du Développement Social du Mali, L'Unité de Mise en Œuvre de Renforcement du Système de Santé, Bamako, Mali
| | - Madeleine Beebe
- Ministère de la Santé et du Développement Social du Mali, L'Unité de Mise en Œuvre de Renforcement du Système de Santé, Bamako, Mali
| | - Moussa Samake
- Ministère de la Santé et du Développement Social du Mali, Cellule de Planification et de Statistique Secteur Santé, Développment Social et Promotion de la Famille, Bamako, Mali
| | - Mamoutou Diabaté
- Ministère de la Santé et du Développement Social du Mali, Direction National de la Santé, Bamako, Mali
| | - Salimata Tounkara
- Ministère de la Santé et du Développement Social du Mali, Direction Générale de la Santé et de l'Hygiène Publique, Bamako, Mali
| | - Borodjan Diarra
- Ministère de la Santé et du Développement Social du Mali, Direction Générale de la Santé et de l'Hygiène Publique, Bamako, Mali
| | - Amadou B Diarra
- Ministère de la Santé et du Développement Social du Mali, L'Unité de Mise en Œuvre de Renforcement du Système de Santé, Bamako, Mali
- MUSO, Bamako, Mali
| | - Cheickna H Diawara
- Ministère de la Santé et du Développement Social du Mali, L'Unité de Mise en Œuvre de Renforcement du Système de Santé, Bamako, Mali
- MUSO, Bamako, Mali
| | - Tsvetana Yakimova
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Sonia Florisse
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Debra Jackson
- University of the Western Cape, School of Public Health, Bellville, Republic of South Africa
- London School of Hygiene and Tropical Medicine (LSHTM), Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London, United Kingdom
| | - Nicolas Ray
- Faculty of Medicine, GeoHealth group, Institute of Global Health, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Tanya Doherty
- University of the Western Cape, School of Public Health, Bellville, Republic of South Africa
- South African Medical Research Council, Health Systems Research Unit, Tygerberg, Republic of South Africa
| |
Collapse
|
31
|
Ogutu M, Muraya K, Mockler D, Darker C. Factors influencing the performance of community health volunteers working within urban informal settlements in low- and middle-income countries: a qualitative meta-synthesis review. HUMAN RESOURCES FOR HEALTH 2021; 19:144. [PMID: 34838044 PMCID: PMC8626887 DOI: 10.1186/s12960-021-00691-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/13/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND There is limited information on community health volunteer (CHV) programmes in urban informal settlements in low- and middle-income countries (LMICs). This is despite such settings accounting for a high burden of disease. Many factors intersect to influence the performance of CHVs working in urban informal settlements in LMICs. This review was conducted to identify both the programme level and contextual factors influencing performance of CHVs working in urban informal settlements in LMICs. METHODS Four databases were searched for qualitative and mixed method studies focusing on CHVs working in urban and peri-urban informal settlements in LMICs. We focused on CHV programme outcome measures at CHV individual level. A total of 13 studies met the inclusion criteria and were double read to extract relevant data. Thematic coding was conducted, and data synthesized across ten categories of both programme and contextual factors influencing CHV performance. Quality was assessed using both the Critical Appraisal Skills Programme (CASP) and the Mixed Methods Assessment Tool (MMAST); and certainty of evidence evaluated using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach. RESULTS Key programme-level factors reported to enhance CHV performance in urban informal settlements in LMICs included both financial and non-financial incentives, training, the availability of supplies and resources, health system linkage, family support, and supportive supervision. At the broad contextual level, factors found to negatively influence the performance of CHVs included insecurity in terms of personal safety and the demand for financial and material support by households within the community. These factors interacted to shape CHV performance and impacted on implementation of CHV programmes in urban informal settlements. CONCLUSION This review identified the influence of both programme-level and contextual factors on CHVs working in both urban and peri-urban informal settlements in LMICs. The findings suggest that programmes working in such settings should consider adequate remuneration for CHVs, integrated and holistic training, adequate supplies and resources, adequate health system linkages, family support and supportive supervision. In addition, programmes should also consider CHV personal safety issues and the community expectations.
Collapse
Affiliation(s)
- Michael Ogutu
- Health Systems & Research Ethics Department, KEMRI-Wellcome Trust Research Programme, P.O Box 43640-00100, Nairobi, Kenya
- Trinity Centre for Global Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Kui Muraya
- Health Systems & Research Ethics Department, KEMRI-Wellcome Trust Research Programme, P.O Box 43640-00100, Nairobi, Kenya
| | - David Mockler
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Catherine Darker
- Public Health & Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
32
|
Gadsden T, Mabunda SA, Palagyi A, Maharani A, Sujarwoto S, Baddeley M, Jan S. Performance-based incentives and community health workers' outputs, a systematic review. Bull World Health Organ 2021; 99:805-818. [PMID: 34737473 PMCID: PMC8542270 DOI: 10.2471/blt.20.285218] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries. METHODS We conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes. FINDINGS Two reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs' efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported. CONCLUSION Financial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed.
Collapse
Affiliation(s)
- Thomas Gadsden
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| | - Sikhumbuzo A Mabunda
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| | - Asri Maharani
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, England
| | - Sujarwoto Sujarwoto
- Department of Public Administration, University of Brawijaya, Malang, Indonesia
| | - Michelle Baddeley
- UTS Business School, University of Technology Sydney, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5/1 King St, Newtown 2042, New South Wales, Australia
| |
Collapse
|
33
|
Sarmiento Medina MI, Caicedo Montaño CA, Ardila Sierra AM, Calderón Barrera JA, Martínez Rodríguez MA, Rivera Triana DP. Albergues temporales como apoyo a la accesibilidad al tercer nivel de atención para poblaciones rurales dispersas: experiencias de pacientes y acompañantes. REPERTORIO DE MEDICINA Y CIRUGÍA 2021. [DOI: 10.31260/repertmedcir.01217372.1152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introducción: los servicios de salud en salud zonas rurales dispersas se han focalizado en la atención primaria. Para lograr integralidad es necesario brindar accesibilidad a los servicios de tercer nivel, lo que representa un reto para los sistemas de salud por los costos y la disponibilidad de profesionales. Varios países desplazan especialistas y equipos a las zonas rurales; en Colombia son los pacientes quienes se trasladan a los centros especializados y las aseguradoras en salud administran dineros provenientes del estado para cubrir los costos. Para ello se requiere el apoyo de albergues temporales que brinden alojamiento y alimentación a pacientes y familiares de bajos recursos. Métodos: estudio cualitativo de caso con enfoque fenomenológico para conocer la experiencia de los usuarios de dos albergues que atienden pacientes y acompañantes provenientes de una zona distante 700 km de Bogotá. Resultados: los servicios de los albergues son bien percibidos por los usuarios, aunque se destacan aspectos locativos por mejorar. El servicio se focaliza en hospedaje, transporte y alimentación quedando un vacío en otras necesidades como ocupación del tiempo libre, apoyo emocional y social. La demora en la atención en salud es la principal causa de inconformidad pues afecta la cotidianidad de las familias por el desplazamiento y la incomunicación. Conclusiones: la atención especializada trasladando pacientes de las zonas dispersas a los centros urbanos representa una experiencia innovadora que debe ser evaluada desde el punto de vista económico y emocional para analizar su relación costo beneficio y su sostenibilidad.
Collapse
|
34
|
Ngwira C, Mayhew SH, Hutchinson E. Community-level integration of health services and community health workers' agency in Malawi. Soc Sci Med 2021; 291:114463. [PMID: 34653684 DOI: 10.1016/j.socscimed.2021.114463] [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: 06/23/2021] [Revised: 09/01/2021] [Accepted: 10/06/2021] [Indexed: 11/28/2022]
Abstract
Despite a large literature on integration of health services, there is a dearth of scholarship assessing service integration in its totality at the community level. Similarly, across the wide evidence base on community health workers (CHWs), there is little that analyses the ways in which they interact with both formal and informal structures and how these interactions shape their agency and ultimately the delivery of integrated services. A better understanding of agency in the work of CHWs would help health systems, policy makers and practitioners to better design and support the delivery of community-level integrated health packages to improve health outcomes. In this study, we explored the agency of CHWs in Malawi known as Health Surveillance Assistants (HSAs). We used qualitative methods: participant observation, in-depth interviews, and focus group discussions between July and October 2018. Overall, the ethnographic study utilised actors-centred frameworks (structuration theory and street-level bureaucracy). The study findings unravel the complexities involving HSAs' agency shaped by health system structures (staffing, infrastructure, drugs, and supplies) and informal structures (community relations, local power structures, gendered-household relations) which narrowed or widened their discretionary decision-making space. The flexibility of HSAs was a distinctive feature in their work, but they developed other coping mechanisms: task shifting, teamwork, creative community engagement, and referrals to deliver integrated maternal and child health services. HSAs' unique position as community-based providers meant they needed to consider diverse factors that constrained or facilitated their work. Overall, we argue that HSAs need to be fully involved in the design of community-level integrated health programmes. There should be a consideration to address both informal and formal structures that together shape agency. Additionally, CHWs' flexibility and agency to make locally informed decisions must be protected and maintained because it enhances their ability to deliver essential health services.
Collapse
Affiliation(s)
- Chikosa Ngwira
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock, London, WC1H 9SH, United Kingdom.
| | - Susannah H Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.
| |
Collapse
|
35
|
Hodgins S, Kok M, Musoke D, Lewin S, Crigler L, LeBan K, Perry HB. Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes. Health Res Policy Syst 2021; 19:109. [PMID: 34641886 PMCID: PMC8506102 DOI: 10.1186/s12961-021-00752-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era". METHODS Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail. RESULTS The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal? CONCLUSION CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential.
Collapse
Affiliation(s)
- Stephen Hodgins
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo Town, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Lauren Crigler
- Crigler Consulting, LLC, Hillsborough, NC, United States of America
| | - Karen LeBan
- Independent Consultant, Washington, DC, United States of America
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
| |
Collapse
|
36
|
Afzal MM, Pariyo GW, Lassi ZS, Perry HB. Community health workers at the dawn of a new era: 2. Planning, coordination, and partnerships. Health Res Policy Syst 2021; 19:103. [PMID: 34641912 PMCID: PMC8506104 DOI: 10.1186/s12961-021-00753-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) play a critical role in grassroots healthcare and are essential for achieving the health-related Sustainable Development Goals. While there is a critical shortage of essential health workers in low- and middle-income countries, WHO and international partners have reached a consensus on the need to expand and strengthen CHW programmes as a key element in achieving Universal Health Coverage (UHC). The COVID-19 pandemic has further revealed that emerging health challenges require quick local responses such as those utilizing CHWs. This is the second paper of our 11-paper supplement, "Community health workers at the dawn of a new era". Our objective here is to highlight questions, challenges, and strategies for stakeholders to consider while planning the introduction, expansion, or strengthening of a large-scale CHW programme and the complex array of coordination and partnerships that need to be considered. METHODS The authors draw on the outcomes of discussions during key consultations with various government leaders and experts from across policy, implementation, research, and development organizations in which the authors have engaged in the past decade. These include global consultations on CHWs and global forums on human resources for health (HRH) conferences between 2010 and 2014 (Montreux, Bangkok, Recife, Washington DC). They also build on the authors' direct involvement with the Global Health Workforce Alliance. RESULTS Weak health systems, poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries. This paper highlights the three issues that are generally agreed as being critical to the long-term effectiveness of national CHW programmes-planning, coordination, and partnerships. Mechanisms are available in many countries such as the UHC2030 (formerly International Health Partnership), country coordinating mechanisms (CCMs), and those focusing on the health workforce such as the national Human Resources for Health Observatory and the Country Coordination and Facilitation (CCF) initiatives introduced by the Global Health Workforce Alliance. CONCLUSION It is imperative to integrate CHW initiatives into formal health systems. Multidimensional interventions and multisectoral partnerships are required to holistically address the challenges at national and local levels, thereby ensuring synergy among the actions of partners and stakeholders. In order to establish robust and institutionalized processes, coordination is required to provide a workable platform and conducive environment, engaging all partners and stakeholders to yield tangible results.
Collapse
Affiliation(s)
| | - George W Pariyo
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zohra S Lassi
- Robinson Research Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
37
|
Glenn J, Moucheraud C, Payán DD, Crook A, Stagg J, Sarma H, Ahmed T, Epstein A, Luies SK, Rahman M, Kruk ME, Bossert TJ. What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh. BMC Health Serv Res 2021; 21:979. [PMID: 34535147 PMCID: PMC8447563 DOI: 10.1186/s12913-021-06996-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 09/07/2021] [Indexed: 12/03/2022] Open
Abstract
Background Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh. Methods This qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach. Results Results suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities. Conclusions This study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.
Collapse
Affiliation(s)
- Jeffrey Glenn
- Department of Public Health, College of Life Sciences, Brigham Young University, 2032 LSB, Provo, UT, 84602, USA.
| | - Corrina Moucheraud
- Department of Health Policy and Management, University of California Los Angeles, Fielding School of Public Health, Los Angeles, CA, USA
| | - Denise Diaz Payán
- Department of Public Health, School of Social Sciences, Humanities and Arts, University of California Merced, Merced, CA, USA
| | - Allison Crook
- Department of Public Health, College of Life Sciences, Brigham Young University, 2032 LSB, Provo, UT, 84602, USA
| | - James Stagg
- Department of Public Health, College of Life Sciences, Brigham Young University, 2032 LSB, Provo, UT, 84602, USA
| | - Haribondhu Sarma
- Research School of Population Health, Australian National University, Acton, ACT, 2601, Australia
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Adrienne Epstein
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Mahfuzur Rahman
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thomas J Bossert
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
38
|
Ludwick T, Endrias M, Morgan A, Kane S, McPake B. Moving From Community-Based to Health-Centre Based Management: Impact on Urban Community Health Worker Performance in Ethiopia. Health Policy Plan 2021; 37:169-188. [PMID: 34519336 DOI: 10.1093/heapol/czab112] [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] [Received: 04/15/2021] [Revised: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
Abstract
Community health worker (CHW) performance is influenced by the way in which management arrangements are configured vis-a-vis the community and health services. While low/middle-income contexts are changing, the literature provides few examples of country efforts to strategically modify management arrangements to support evolving CHW roles (e.g. chronic disease care) and operating environments (e.g. urbanization). This paper aims to understand the performance implications of changing from community-based to health centre-based management, on Ethiopia's Urban Health Extension Professionals (UHEPs), and the tensions/trade-offs associated with the respective arrangements. We conducted semi-structured interviews/focus groups to gather perspectives and preferences from those involved with the transition (13 managers/administrators, 5 facility-based health workers, 20 UHEPs). Using qualitative content analysis, we deductively coded data to four program elements impacted by changed management arrangements and known to affect CHW performance (work scope; community legitimacy; supervision/oversight/ownership; facility linkages) and inductively identified tensions/trade-offs. Community-based management was associated with wider work scope, stronger ownership/regular monitoring, weak technical support, and weak health center linkages, with opposite patterns observed for health center-led management. Practical trade-offs included: heavy UHEP involvement in political/administrative activities under Kebele-based management; resistance to working with UHEPs by facility-based workers; and, health centre capacity constraints in managing UHEPs. Whereas the Ministry of Health/UHEPs favoured health centre-led management to capitalize on UHEPs' technical skills, Kebele officials were vested in managing UHEPs and argued for community interests over UHEPs' professional interests; health facility managers/administrators held divided opinions. Management arrangements influence the nature of CHW contributions towards the achievement of health, development, and political goals. Decisions about appropriate management arrangements should align with the nature of CHW roles and consider implementation setting, including urbanization, political decentralization, and relative capacity of managing institutions.
Collapse
Affiliation(s)
- Teralynn Ludwick
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, 333 Exhibition Street, Carlton, Victoria, Australia
| | - Misganu Endrias
- Health Research and Technology Transfer Office, SNNPR Regional Health Bureau, Hawassa, Ethiopia
| | - Alison Morgan
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Global Financing Facility, The World Bank Group, Washington, DC, USA
| | - Sumit Kane
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Barbara McPake
- Nossal Institute for Global Health Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| |
Collapse
|
39
|
Newton-Lewis T, Nanda P. Problematic problem diagnostics: why digital health interventions for community health workers do not always achieve their desired impact. BMJ Glob Health 2021; 6:bmjgh-2021-005942. [PMID: 34312157 PMCID: PMC8728339 DOI: 10.1136/bmjgh-2021-005942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/16/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Priya Nanda
- Measurement, Learning, and Evaluation, Bill & Melinda Gates Foundation India, New Delhi, India
| |
Collapse
|
40
|
Framing the Integration of Community Health Workers Into Health Care Systems Along Health Care and Community Spectrums. J Ambul Care Manage 2021; 44:271-280. [PMID: 34347715 DOI: 10.1097/jac.0000000000000396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Research calls for community health worker (CHW) integration within health systems, yet there is no agreement regarding what CHW integration is or guidance for how it can be achieved. This study examines factors associated with CHW integration in community and health care settings using a qualitative descriptive multiple-embedded case study of CHW teams at the University of Illinois at Chicago. Data were collected via semistructured interviews/document review and analyzed using thematic coding and quantitative content analysis. Factors associated with higher clinical integration included culture, communication, protocols, and training while higher community integration was associated with accessibility, relationships, and empathy.
Collapse
|
41
|
Abuya T, Mwanga D, Obadha M, Ndwiga C, Odwe G, Kavoo D, Wanyugu J, Warren C, Agarwal S. Incentive preferences for community health volunteers in Kenya: findings from a discrete choice experiment. BMJ Open 2021; 11:e048059. [PMID: 34226227 PMCID: PMC8258597 DOI: 10.1136/bmjopen-2020-048059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Community health volunteers (CHVs) play crucial roles in enabling access to healthcare at the community levels. Although CHVs are considered volunteers, programmes provide financial and non-financial incentives. However, there is limited evidence on which bundle of financial and non-financial incentives are most effective for their improved performance. METHODS We used a discrete choice experiment (DCE) to understand incentive preferences of CHVs with the aim to improve their motivation, performance and retention. Relevant incentive attributes were identified through qualitative interviews with CHVs and with their supervisors. We then deployed a nominal group technique to generate and rank preferred attributes among CHVs. We developed a DCE based on the five attributes and administered it to 211 CHVs in Kilifi and Bungoma counties in Kenya. We used mixed multinomial logit models to estimate the utility of each incentive attribute and calculated the trade-offs the CHWs were willing to make for a change in stipend. RESULTS Transport was considered the incentive attribute with most relative importance followed by tools of trade then monthly stipend. CHVs preferred job incentives that offered higher monthly stipends even though it was not the most important. They had negative preference for job incentives that provided award mechanisms for the best performing CHVs as compared with jobs that provided recognition at the community level and preferred job incentives that provided more tools of trade compared with those that provided limited tools. CONCLUSION A bundled incentive of both financial and non-financial packages is necessary to provide a conducive working environment for CHVs. The menu of options relevant for CHVs in Kenya include transport, tools of trade and monthly stipend. Policy decisions should be contextualised to include these attributes to facilitate CHW satisfaction and performance.
Collapse
Affiliation(s)
- Timothy Abuya
- Reproductive Health, Population Council, Nairobi, Kenya
| | - Daniel Mwanga
- Reproductive Health, Population Council, Nairobi, Kenya
| | - Melvin Obadha
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - George Odwe
- Reproductive Health, Population Council, Nairobi, Kenya
| | - Daniel Kavoo
- Division of Community Health Services, Minsitry of Health, Nairobi, Kenya
| | - John Wanyugu
- Division of Community Health Services, Minsitry of Health, Nairobi, Kenya
| | | | - Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
42
|
Community health volunteers challenges and preferred income generating activities for sustainability: a qualitative case study of rural Kilifi, Kenya. BMC Health Serv Res 2021; 21:642. [PMID: 34217281 PMCID: PMC8254366 DOI: 10.1186/s12913-021-06693-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 06/23/2021] [Indexed: 12/05/2022] Open
Abstract
Background There is a global emphasis on engaging community health volunteers (CHVs) in low- to middle-income countries (LMICs) to reach to the vast underserved populations that live in rural areas. Retention of CHVs in most countries has however been difficult and turnover in many settings has been reported to be high with profound negative effects on continuity of community health services. In rural Kenya, high attrition among CHVs remains a concern. Understanding challenges faced by CHVs in rural settings and how to reduce attrition rates with sustainable income-generating activities (IGAs) is key to informing the implementation of contextual measures that can minimise high turnover. This paper presents findings on the challenges of volunteerism in community health and the preferred IGAs in rural Kilifi county, Kenya. Methods The study employed qualitative methods. We conducted 8 key informant interviews (KIIs) with a variety of stakeholders and 10 focus group discussions (FGDs) with CHVs. NVIVO software was used to organise and analyse our data thematically. Results Community Health Volunteers work is not remunerated and it conflicts with their economic activities, child care and other community expectations. In addition, lack of supervision, work plans and relevant training is a barrier to delivering CHVs’ work to the communities. There is a need to remunerate CHVs work as well as provide support in the form of basic training and capital on entrepreneurship to implement the identified income generating activities such as farming and events management. Conclusions Strategies to support the livelihoods of CHVs through context relevant income generating activities should be identified and co-developed by the ministry of health and other stakeholders in consultation with the CHVs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06693-w.
Collapse
|
43
|
Dodd W, Kipp A, Nicholson B, Lau LL, Little M, Walley J, Wei X. Governance of community health worker programs in a decentralized health system: a qualitative study in the Philippines. BMC Health Serv Res 2021; 21:451. [PMID: 33980209 PMCID: PMC8114679 DOI: 10.1186/s12913-021-06452-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/26/2021] [Indexed: 12/22/2022] Open
Abstract
Background Community health worker (CHW) programs are an important resource in the implementation of universal health coverage (UHC) in many low- and middle-income countries (LMICs). However, in countries with decentralized health systems like the Philippines, the quality and effectiveness of CHW programs may differ across settings due to variations in resource allocation and local politics. In the context of health system decentralization and the push toward UHC in the Philippines, the objective of this study was to explore how the experiences of CHWs across different settings were shaped by the governance and administration of CHW programs. Methods We conducted 85 semi-structured interviews with CHWs (n = 74) and CHW administrators (n = 11) in six cities across two provinces (Negros Occidental and Negros Oriental) in the Philippines. Thematic analysis was used to analyze the qualitative data with specific attention to how the experiences of participants differed within and across geographic settings. Results Health system decentralization contributed to a number of variations across settings including differences in the quality of human resources and the amount of financial resources allocated to CHW programs. In addition, the quality and provider of CHW training differed across settings, with implications for the capacity of CHWs to address specific health needs in their community. Local politics influenced the governance of CHW programs, with CHWs often feeling pressure to align themselves politically with local leaders in order to maintain their employment. Conclusions The functioning of CHW programs can be challenged by health system decentralization through the uneven operationalization of national health priorities at the local level. Building capacity within local governments to adequately resource CHWs and CHW programs will enhance the potential of these programs to act as a bridge between the local health needs of communities and the public health system. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06452-x.
Collapse
Affiliation(s)
- Warren Dodd
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, N2L 3G1, Canada.
| | - Amy Kipp
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, N2L 3G1, Canada
| | - Bethany Nicholson
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. W, Waterloo, Ontario, N2L 3G1, Canada
| | | | - Matthew Little
- School of Public Health and Social Policy, University of Victoria, Victoria, Canada
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| |
Collapse
|
44
|
Gottert A, McClair TL, Hossain S, Dakouo SP, Abuya T, Kirk K, Bellows B, Agarwal S, Kennedy S, Warren C, Sripad P. Development and validation of a multi-dimensional scale to assess community health worker motivation. J Glob Health 2021; 11:07008. [PMID: 33763222 PMCID: PMC7957275 DOI: 10.7189/jogh.11.07008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Ensuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being - and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation. METHODS Scale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables. RESULTS The final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention. CONCLUSIONS We found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.
Collapse
Affiliation(s)
- Ann Gottert
- Population Council, Washington D.C. & New York, New York, USA
| | - Tracy L McClair
- Population Council, Washington D.C. & New York, New York, USA
| | | | | | | | - Karen Kirk
- Population Council, Washington D.C. & New York, New York, USA
| | - Ben Bellows
- Population Council, Washington D.C. & New York, New York, USA
| | - Smisha Agarwal
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sarah Kennedy
- Population Council, Washington D.C. & New York, New York, USA
| | | | - Pooja Sripad
- Population Council, Washington D.C. & New York, New York, USA
| |
Collapse
|
45
|
Sripad P, McClair TL, Casseus A, Hossain S, Abuya T, Gottert A. Measuring client trust in community health workers: A multi-country validation study. J Glob Health 2021; 11:07009. [PMID: 33763223 PMCID: PMC7956104 DOI: 10.7189/jogh.11.07009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Client trust in community health workers (CHWs) is integral for improving quality and equity of community health systems globally. Despite its recognized conceptual and pragmatic importance across health areas, there are no quantitative measures of trust in the context of community health services. In this multi-country study, we aimed to develop and validate a scale that assesses trust in CHWs. METHODS To develop the scale, we used a consultative process to conceptualize and adapt items and domains from prior literature to the CHW context. Content validity and comprehension of scale items were validated through 10 focus group discussions with 75 community members in Haiti, and Kenya. We then conducted 1939 surveys with clients who interacted with CHWs recently in Bangladesh (n = 1017), Haiti (n = 616), and Kenya (n = 306). To analyze the 15 candidate scale items we conducted a split sample exploratory/confirmatory factor analysis (EFA/CFA), and then assessed internal consistency reliability of resulting set of items. Finally, we assessed convergent validity via multivariable models examining associations between final scale scores with theoretically related constructs. RESULTS Factor analyses resulted in a 10-item Trust in CHWs Scale with two factors (sub-scales): Health care competence (5 items) and Respectful communication (5 items). The qualitative data also underscored these two sub-domains. The full scale had good internal consistency reliability in Bangladesh, Haiti and Kenya (alphas 0.87, 0.86, and 0.92, respectively; all alphas for subscales were also > 0.7, most > 0.8). Greater scores on Trust in CHWs were positively associated with increased client empowerment, familiarity with CHWs, satisfaction with recent client-CHW interaction, and positive influence of CHW on client empowerment. Scale scores were not influenced by the age, sex, parity, education, and wealth quintiles in across countries and may be affected by contextual factors. CONCLUSIONS The Trust in CHWs Scale, which includes Health care competence and Respectful communication sub-scales, is the first such scale developed and validated globally. Our findings suggest this 10-item scale is a reliable and valid tool for quantifying clients' trust in CHWs, with potential utility for tracking and improving CHW and health systems performance over time.
Collapse
|
46
|
Sharma S, Arora K, Chandrashekhar, Sinha RK, Akhtar F, Mehra S. Evaluation of a training program for life skills education and financial literacy to community health workers in India: a quasi-experimental study. BMC Health Serv Res 2021; 21:46. [PMID: 33419442 PMCID: PMC7796593 DOI: 10.1186/s12913-020-06025-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background Accredited Social Health Activists (ASHA) are community health workers responsible for improving the health status of people by facilitating their access to healthcare services. The life skills of ASHA are known to be effective in negotiating behaviour change in the community; however, there has been a meagre focus towards improving them. Considering this gap, we adopted a comprehensive training program, known as Personal Advancement and Career Enhancement (P.A.C.E.), to empower ASHAs on life skills and financial literacy. The present study intends to assess the training program in two districts of Uttar Pradesh, India, by examining changes in knowledge, perceptions, and practices of ASHAs about life skills and financial literacy. Methods We conducted a quasi-experimental, non-randomized, controlled study with pre-and post-test assessments. Data were collected on socio-demographic characteristics, knowledge, and practices related to life skills (communication skills, self-confidence, problem–solving and decision-making skills, time and stress management skills) and financial literacy. Additionally, change perceptions on gender-, life skills-, and savings-related practices at the personal, community, and workplace levels were assessed in the intervention group. Factor analysis was performed to obtain the change patterns by assessing the degree to which the four life skills, financial literacy, and change perceptions on practices were correlated. A general linear regression model was performed to assess associations among change pattern scores and socio-demographic variables. Results We analyzed the data of 171 ASHAs (intervention group:86 and control group:85). There was a significant improvement in the average post-test scores of all the life skills and financial literacy in the intervention group (p < 0.001). Three distinct change patterns were found post-training in the intervention group. Factor 1 (high loadings for change perceptions on practices) was positively associated with ASHAs aged 38 and above and with experience of ≤12 years. On the contrary, the change in financial literacy and self-confidence scores was common among ASHAs with more than 12 years of experience. Conclusions The P.A.C.E training program was found effective in improving the life skills and financial literacy of ASHAs in India. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06025-4.
Collapse
Affiliation(s)
- Shantanu Sharma
- Department of Clinical Sciences, Lund University, Skåne University Hospital, S-20502 Malmö, Sweden & Assistant Director, MAMTA Health Institute for Mother and Child, Delhi, India.
| | - Kanishtha Arora
- Reproductive, Maternal, Newborn, Child and Adolescent Health Division, MAMTA Health Institute for Mother and Child, Delhi, India
| | - Chandrashekhar
- MAMTA Health Institute for Mother and Child, Delhi, India
| | - Rajesh Kumar Sinha
- Reproductive, Maternal, Newborn, Child and Adolescent Health Division, MAMTA Health Institute for Mother and Child, Delhi, India
| | - Faiyaz Akhtar
- Reproductive, Maternal, Newborn, Child and Adolescent Health Division, MAMTA Health Institute for Mother and Child, Delhi, India
| | - Sunil Mehra
- MAMTA Health Institute for Mother and Child, Delhi, India
| |
Collapse
|
47
|
Kawade A, Gore M, Lele P, Chavan U, Pinnock H, Smith P, Juvekar S. Interplaying role of healthcare activist and homemaker: a mixed-methods exploration of the workload of community health workers (Accredited Social Health Activists) in India. HUMAN RESOURCES FOR HEALTH 2021; 19:7. [PMID: 33407518 PMCID: PMC7789492 DOI: 10.1186/s12960-020-00546-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/09/2020] [Indexed: 05/24/2023]
Abstract
BACKGROUND Globally, community health workers (CHWs) are integral contributors to many health systems. In India, Accredited Social Health Activists (ASHAs) have been deployed since 2005. Engaged in multiple health care activities, they are a key link between the health system and population. ASHAs are expected to participate in new health programmes prompting interest in their current workload from the perspective of the health system, community and their family. METHODS This mixed-methods design study was conducted in rural and tribal Primary Health Centers (PHCs), in Pune district, Western Maharashtra, India. All ASHAs affiliated with these PHCs were invited to participate in the quantitative study, those agreeing to contribute in-depth interviews (IDI) were enrolled in an additional qualitative study. Key informants' interviews were conducted with the Auxiliary Nurse Midwife (ANM), Block Facilitators (BFF) and Medical Officers (MO) of the same PHCs. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed thematically. RESULTS We recruited 67 ASHAs from the two PHCs. ASHAs worked up to 20 h/week in their village of residence, serving populations of approximately 800-1200, embracing an increasing range of activities, despite a workload that contributed to feelings of being rushed and tiredness. They juggled household work, other paid jobs and their ASHA activities. Practical problems with travel added to time involved, especially in tribal areas where transport is lacking. Their sense of benefiting the community coupled with respect and recognition gained in village brought happiness and job satisfaction. They were willing to take on new tasks. ASHAs perceived themselves as 'voluntary community health workers' rather than as 'health activists". CONCLUSIONS ASHAs were struggling to balance their significant ASHA work and domestic tasks. They were proud of their role as CHWs and willing to take on new activities. Strategies to recruit, train, skills enhancement, incentivise, and retain ASHAs, need to be prioritised. Evolving attitudes to the advantages/disadvantages of current voluntary status and role of ASHAs need to be understood and addressed if ASHAs are to be remain a key component in achieving universal health coverage in India.
Collapse
Affiliation(s)
- Anand Kawade
- Vadu Rural Health Program, King Edward Memorial Hospital Research Centre (KEMHRC), Rasta Peth, Pune, Maharashtra, 411011, India.
| | - Manisha Gore
- Symbiosis Institute of Health Sciences, Symbiosis International (Deemed) University, Lavale, Mulshi, Pune, Maharashtra, 411011, India
| | - Pallavi Lele
- Vadu Rural Health Program, King Edward Memorial Hospital Research Centre (KEMHRC), Rasta Peth, Pune, Maharashtra, 411011, India
| | - Uddhavi Chavan
- Vadu Rural Health Program, King Edward Memorial Hospital Research Centre (KEMHRC), Rasta Peth, Pune, Maharashtra, 411011, India
| | - Hilary Pinnock
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE) Usher Institute, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, United Kingdom
| | - Pam Smith
- Nursing Studies, School of Health in Social Science, NIHR Global Health Research Unit on Respiratory Health (RESPIRE), University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, United Kingdom
| | - Sanjay Juvekar
- Vadu Rural Health Program, King Edward Memorial Hospital Research Centre (KEMHRC), Rasta Peth, Pune, Maharashtra, 411011, India
| |
Collapse
|
48
|
Mahmood H, Mckinstry B, Luz S, Fairhurst K, Nasim S, Hazir T. Community health worker-based mobile health (mHealth) approaches for improving management and caregiver knowledge of common childhood infections: A systematic review. J Glob Health 2020; 10:020438. [PMID: 33437462 PMCID: PMC7774026 DOI: 10.7189/jogh.10.020438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Children in lower middle-income countries (LMICs) are more at risk of dying, than those in High Income Countries (HICs), due to highly prevalent deadly yet preventable childhood infections. Alongside concerns about the incidence of these infections, there has been a renewed interest in involving community health workers (CHWs) in various public health programs. However, as CHWs are increasingly asked to take on different tasks there is a risk that their workload may become unmanageable. One solution to help reduce this burden is the use of mobile health (mHealth) technology in the community through behaviour change. Considering there are various CHWs based mHealth approaches on illness management and education, therefore, we aimed to appraise the available literature on effectiveness of these mHealth approaches for caregivers to improve knowledge and management about common under-five childhood infections with respect to behaviour change. Methods We searched six databases between October to December 2019 using subject heading (Mesh) and free text terms in title or abstract in US English. We included multiple study types of children under-five or their caregivers who have been counselled, educated, or provided any health care service by CHWs for any common paediatric infectious diseases using mHealth. We excluded articles published prior to 1990 and those including mHealth technology not coming under the WHO definition. A data extraction sheet was developed and titles, abstracts, and selected full text were reviewed by two reviewers. Quality assessment was done using JBI tools. Results We included 23 articles involving around 300 000 individuals with eight types of study designs. 20 studies were conducted in Africa, two in Asia, and one in Latin America mainly on pneumonia or respiratory tract infections followed by malaria and diarrhoea in children. The most common types of Health approaches were mobile applications for decision support, text message reminders and use of electronic health record systems. None of the studies employed the use of any behaviour change model or any theoretical framework for selection of models in their studies. Conclusions Coupling mhealth with CHWs has the potential to benefit communities in improving management of illnesses in children under-five. High quality evidence on impact of such interventions on behaviour is relatively sparse and further studies should be conducted using theoretically informed behaviour change frameworks/models. Registration PROPSERO Registration number: CRD42018117679
Collapse
Affiliation(s)
- Hana Mahmood
- Maternal, Neonatal and Child Health Research Network (MNCHRN), Pakistan.,NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
| | - Brian Mckinstry
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
| | - Saturnino Luz
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
| | - Karen Fairhurst
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
| | - Sumaira Nasim
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
| | - Tabish Hazir
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, the University of Edinburgh, Edinburgh, UK
| | | |
Collapse
|
49
|
Gupta M, Roy S, Panda R, Konwar P, Jagnoor J. Interventions for Child Drowning Reduction in the Indian Sundarbans: Perspectives from the Ground. CHILDREN-BASEL 2020; 7:children7120291. [PMID: 33327539 PMCID: PMC7765013 DOI: 10.3390/children7120291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 02/03/2023]
Abstract
Drowning is a leading cause of child death in the coastal Sundarbans region of India due to the presence of open water, lack of supervision and poor infrastructure, but no prevention programs are currently implemented. The World Health Organization has identified interventions that may prevent child drowning in rural low-and middle-income country contexts, including the provision of home-based barriers, supervised childcare, swim and rescue training and first responder training. Child health programs should consider the local context and identify barriers for implementation. To ensure the sustainability of any drowning prevention programs implemented, we conducted a qualitative study to identify the considerations for the implementation of these interventions, and to understand how existing government programs could be leveraged. We also identified key stakeholders for involvement. We found that contextual factors such as geography, cultural beliefs around drowning, as well as skillsets of local people, would influence program delivery. Government programs such as accredited social health activists (ASHAs) and self-help groups could be leveraged for program implementation, while Anganwadi centres would require additional support due to poor resourcing. Gaining government permissions to change Anganwadi processes to provide childcare services may be challenging. The results showed that adapting drowning programs to the Sundarbans context presents unique challenges and program customisation.
Collapse
Affiliation(s)
- Medhavi Gupta
- The George Institute for Global Health Australia, University of New South Wales, Level 5, 1 King St, Newtown, NSW 2042, Australia;
| | - Sujoy Roy
- Child in Need Institute, Daulatpur, Pailan, South 24 Parganas, West Bengal 700104, India; (S.R.); (R.P.)
| | - Ranjan Panda
- Child in Need Institute, Daulatpur, Pailan, South 24 Parganas, West Bengal 700104, India; (S.R.); (R.P.)
| | - Pompy Konwar
- Injury Division, The George Institute for Global Health India, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India;
| | - Jagnoor Jagnoor
- Injury Division, The George Institute for Global Health India, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India;
- Correspondence: ; Tel.: +91-11-4158-8091-93
| |
Collapse
|
50
|
Nanda P, Lewis TN, Das P, Krishnan S. From the frontlines to centre stage: resilience of frontline health workers in the context of COVID-19. Sex Reprod Health Matters 2020; 28:1837413. [PMID: 33054663 PMCID: PMC7887900 DOI: 10.1080/26410397.2020.1837413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Priya Nanda
- Measurement Learning and Evaluation, Bill and Melinda Gates Foundation, India Country Office, New Delhi, India
| | | | - Priya Das
- Senior Consultant, Oxford Policy Management, Delhi, India
| | - Suneeta Krishnan
- Country Lead, Measurement, Learning and Evaluation, Bill and Melinda Gates Foundation, India Country Office, New Delhi, India
| |
Collapse
|