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Evagora-Campbell M, Kedia S, Odero HO, Uppal R, Odunga SA, Mattoo T, Miranda PB, Tanaka S, Kiwuwa-Muyingo S, Verma R, Hawkes S, Buse K. Legislation for advancing women's leadership in the health sector in India and Kenya: a 'law cube' approach to identify ways to strengthen legal environments for gender equality. BMJ Glob Health 2024; 9:e014746. [PMID: 39019546 PMCID: PMC11256037 DOI: 10.1136/bmjgh-2023-014746] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/30/2024] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVES This paper examines the availability of legal provisions, or the lack thereof, that support women to progress equitably into leadership positions within the health workforce in India and Kenya. METHODS We adapted the World Bank's Women, Business and Law framework of legal domains relevant to gender equality in the workplace and applied a 'law cube' to analyse the comprehensiveness, accountability and equity and human rights considerations of 27 relevant statutes in India and 11 in Kenya that apply to people in formal employment within the health sector. We assessed those laws against 30 research-validated good practice measures across five legal domains: (1) pay; (2) workplace protections; (3) pensions; (4) care, family life and work-life balance; and (5) reproductive rights. In India, the pension domain and related measures were not assessed because the pension laws do not apply to the public and private sector equally. RESULTS Several legal domains are addressed inadequately or not at all, including pay in India, reproductive rights in Kenya and the care, family life and the work-life balance domain in both countries. Additionally, we found that among the Kenyan laws reviewed, few specify accountability mechanisms, and equity and human rights measures are mainly absent from the laws assessed in both countries. Our findings highlight inadequacies in the legal environments in India and Kenya may contribute to women's under-representation in leadership in the health sector. The absence of specified accountability mechanisms may impact the effective implementation of legislation, undermining their potential to promote equal opportunities. CONCLUSIONS Government action is needed in both countries to ensure that legislation addresses best practice provisions, equity and human rights considerations, and provides for independent review mechanisms to ensure accountability for implementation of existing and future laws. This would contribute to ensuring that legal environments uphold the equality of opportunity necessary for realising gender justice in the workplace for the health workforce. PRIMARY SOURCE OF FUNDING Bill & Melinda Gates Foundation (INV-031372).
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Affiliation(s)
| | - Sapna Kedia
- International Center for Research on Women (ICRW), New Delhi, India
| | | | - Radhika Uppal
- International Center for Research on Women (ICRW), New Delhi, India
| | | | - Tusharika Mattoo
- International Center for Research on Women (ICRW), New Delhi, India
| | | | | | | | - Ravi Verma
- International Center for Research on Women (ICRW), New Delhi, India
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Gideon J, Asthana S, Bisht R. Health systems in India: analysing barriers to inclusive health leadership through a gender lens. BMJ 2024; 386:e078351. [PMID: 39019544 PMCID: PMC11249731 DOI: 10.1136/bmj-2023-078351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Affiliation(s)
- Jasmine Gideon
- Birkbeck, University of London, London, UK
- Global Health 5050, Cambridge, UK
| | - Sumegha Asthana
- Centre for Global Health Science and Security, Georgetown University, Washington DC, USA
| | - Ramila Bisht
- Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
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Tikkanen RS, Closser S, Prince J, Chand P, Justice J. An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change. Int J Equity Health 2024; 23:70. [PMID: 38614976 PMCID: PMC11015651 DOI: 10.1186/s12939-024-02177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/06/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs). METHODS We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources. RESULTS Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system. CONCLUSIONS Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.
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Affiliation(s)
- Roosa Sofia Tikkanen
- Institute of Sociology and Political Science, Faculty of Social and Educational Sciences, Norwegian University of Science and Technology, Edvard Bulls veg 1, 7491, Trondheim, Norway.
| | - Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, Maryland, 21205, USA
| | - Justine Prince
- Zanvyl Krieger School of Arts & Sciences, Johns Hopkins University, 3400 N. Charles Street, Baltimore, Maryland, 21218, USA
| | - Priyankar Chand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, Maryland, 21205, USA
| | - Judith Justice
- Institute for Health & Aging, School of Nursing, University of California at San Francisco, 490 Illinois Street, San Francisco, CA, 94143, USA
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Shrivastava R, Singh A, Khan A, Choubey S, Haney JR, Karyotaki E, Tugnawat D, Bhan A, Naslund JA. Stress Alleviation Methods for community-Based Health ActiVists (SAMBHAV): Development of a digital program for stress reduction for community health workers in rural India. SSM - MENTAL HEALTH 2023; 4:100230. [PMID: 38188869 PMCID: PMC10769151 DOI: 10.1016/j.ssmmh.2023.100230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024] Open
Abstract
Background Community health workers (CHWs) face high levels of stress (both professional and personal) and risk of burnout, highlighting the need for efforts to promote their mental health and well-being. This study seeks to develop a digital stress reduction program for CHWs in rural India. Methods A stepwise design process was employed to adapt and digitize the evidence-based World Health Organization's Self-Help Plus (SH+) intervention for addressing psychological distress among CHWs in Madhya Pradesh, India. This involved participatory design workshops with CHWs to ensure that the digital stress reduction intervention would be relevant for their needs and the local culture and context. Small groups of CHWs reviewed the adapted program content, allowing the research team to make refinements such as simplifying language, tailoring content to the local setting, and ensuring that program materials are both interesting and relevant. Simultaneously, the research team digitized the content, leveraging a combination of video and graphical content, and uploaded it to the Sangath Learning Management System, a digital platform accessible on a smartphone app. Results In total, 18 CHWs contributed to the adaptation of the SH+ content and digital intervention development. Participants commented on finding some terms difficult to follow and recommended simplifying the language and providing detailed explanations. Participants offered positive feedback on the adapted content, expressing that they found the examples covered in the material both relatable and relevant to their own personal experiences at home and in the workplace. By combining participants' insights and comments with feedback from content experts, it was possible to finalize a digital Hindi version of the SH+ intervention for CHWs in rural India. Conclusions This study is timely given the continued detrimental impacts of the COVID-19 pandemic, and offers a promising and potentially scalable digital program to alleviate psychological distress among frontline health workers.
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Affiliation(s)
| | | | | | | | | | - Eirini Karyotaki
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | | | - John A. Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Saxena SG, Godfrey T. India's Opportunity to Address Human Resource Challenges in Healthcare. Cureus 2023; 15:e40274. [PMID: 37448434 PMCID: PMC10336366 DOI: 10.7759/cureus.40274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
India's health indicators have improved in recent times but continue to lag behind those of its peer nations. The country with a population of 1.3 billion, has an estimated active health workers density of doctors and nurses/midwives of 5.0 and 6.0 respectively, for 10,000 persons, which is much lower than the WHO threshold of 44.5 doctors, nurses, and midwives per 10,000 population. The issue is compounded by the skewed inter-state, urban-rural, and public-private sector divide. Calls to urgently augment the skilled health workforce reinforce the central role human resources have in healthcare, which has evolved into a complex multifactorial issue. The paucity of skilled personnel must be addressed if India is to accelerate its progress toward achieving universal health coverage and its sustainable development goals (SDGs). The recent increase in the federal health budget offers an unprecedented opportunity to do this. This article utilizes the ready materials, extract and analyze data, distill findings (READ) approach to adding to the authors' experiential learning to analyze the health system in India. The growing divide between the public and the burgeoning private health sector systems, with the latter's booming medical tourism industry and medical schools, are analyzed along with the newly minted National Medical Council, to recommend policies that would help India achieve its SDGs.
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Affiliation(s)
| | - Thomas Godfrey
- Public Health Sciences, Penn State College of Medicine, Hershey, USA
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Khan A, Khan S, Khan MA, Zaman K, Khan HUR, Rosman ASB, Indrianti Y, Hassan AA. Economic costs of gender inequality in health and the labor market: India's untapped potential. Front Public Health 2023; 11:1067940. [PMID: 36794076 PMCID: PMC9922756 DOI: 10.3389/fpubh.2023.1067940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Affiliation(s)
- Aqeel Khan
- Faculty of Social Sciences and Humanities, Universiti Teknologi Malaysia (UTM), Skudai, Johor, Malaysia
| | - Shiraz Khan
- Department of Management Sciences, The University of Haripur, Haripur, Pakistan
| | | | - Khalid Zaman
- Department of Economics, The University of Haripur, Haripur, Pakistan,*Correspondence: Khalid Zaman ✉
| | - Haroon ur Rashid Khan
- Faculty of Business, The University of Wollongong in Dubai, Dubai, United Arab Emirates
| | - Arieff Salleh Bin Rosman
- Center of Research for Fiqh Science and Technology (CFIRST), Universiti Teknologi Malaysia (UTM), Skudai, Johor, Malaysia
| | - Yasinta Indrianti
- Entrepreneurship Department, Podomoro University, Jakarta, Indonesia
| | - Abidin Ali Hassan
- Department of Economics and Finance, College of Business Administration, University of Bahrain, Sakheer, Bahrain
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Nichols C, Jalali F, Fischer H. The "Corona Warriors"? Community health workers in the governance of India's COVID-19 response. POLITICAL GEOGRAPHY 2022; 99:102770. [PMID: 36213893 PMCID: PMC9531667 DOI: 10.1016/j.polgeo.2022.102770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 06/10/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
India's nearly 1-million strong band of quasi-volunteer accredited social health activists (ASHAs) have been key actors in government efforts to control COVID-19. Utilizing a nationalist rhetoric of war, ASHAs were swiftly mobilized by the government in March 2020 as 'COVID warriors' engaged in tracking illness, disseminating information, and caring for quarantined individuals. The speed at which ASHAs were mobilized into mentally and physically grueling labor was all the more stunning given these minimally paid community health workers have long been seen to have low morale given their precarious, informalized work arrangements. Building on work examining the spatialities of global health governance alongside literature on geographic contingency, this paper explores the ways that nationalist COVID-19 war rhetoric promulgated from Delhi worked as a technology of health governance to propel ASHAs into certain forms of action, yet also opened up spaces of potentiality for them to reimagine their relationship to both the state and the communities they serve. In particular, in our analysis of in-depth telephone interviews with ASHA workers in the state of Himachal Pradesh, we find that their hailing as COVID warriors inspired patriotic calls to duty and legitimized their (long over-looked) roles as critical governance actors, yet also was subject to resistance and reworking due to a combination of institutional histories, local politics, as well as happenstantial everyday encounters of ASHA work. The precarious employment of ASHAs - in terms of basic remuneration as well as the great on-the-job risks that they have faced - underscores both the fragile nature of India's health governance system as well as possible political movements for its renewal. We conclude by calling for geographers to give greater attention to community health care workers as a key window into understanding the uneven ways in which health systems are made manifest on the ground, and their ability to respond to citizens' healthcare needs - both in the COVID-19 pandemic and beyond.
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Affiliation(s)
- Carly Nichols
- University of Iowa, 312 Jessup Hall, Iowa City, IA, 52245, USA
| | - Falak Jalali
- University of Iowa, 312 Jessup Hall, Iowa City, IA, 52245, USA
| | - Harry Fischer
- Department of Urban and Rural Development, Swedish University of Agricultural Sciences, Sweden
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Seth K, Nanda S, Sahay A, Verma R, Achyut P. Men, The Missing Link In Gender-equitable Family Planning: A Scoping Review. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13536.1] [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
Background: Across societies, gender norms often allow men to hold key decision-making power within relationships, households and communities. This extends to almost all domains, consisting of family planning (FP) as well. FP programs have largely engaged men as clients and rarely as equal partners or influencers although across lower- and middle-income countries (LMICs), and especially in South Asia, men hold key decision-making power on the domain of family planning. The objective of this article is to explore couple dynamics through the lens of spousal communication and decision-making and unpack male engagement and spousal dynamics in family planning. Methods: This review presents a synthesis of evidence from two peer-reviewed databases, PubMed and Jstor, and and insights from programmatic documents to shed light on gender equitable engagement of young married men in family planning. Inclusion and exclusion criteria for both these databases was set and search strategies were finalized. This was followed by title and abstract screening, data extraction, synthesis and analysis. Results: Study participants included unmarried men (16%, n=8), married men (19%, n=9), married women (19%, n=9), married couples (25%, n=12) or more than two respondent categories (21%, n=10). Almost three quarters (71%, n=34) of the studies selected had FP as the primary area of inquiry. Other prominent thematics on which the studies reported were around norms (n=9, 16%), couple dynamics and intimacy (n=12, 22%). Conclusions: The evidence presented provides sufficient impetus to expand on gender-equitable male engagement, viewing men as equal and supportive partners for informed, equitable and collaborative contraceptive uptake and FP choices by couples.
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Ruit C, Breckenridge A. South African community health workers' pursuit of occupational security. GENDER WORK AND ORGANIZATION 2022. [DOI: 10.1111/gwao.12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Catherine Ruit
- Health and Society, Health and Exercise Physiology 033F Hellferich Hall Ursinus College Collegeville Pennsylvania USA
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Kinshella MLW, Boene H, Sevene E, Valá A, Sharma S, Vidler M, Magee LA, von Dadelszen P, Munguambe K, Payne BA. How Gender Influenced the Experience of Using a mHealth Intervention in Rural Mozambique: Secondary Qualitative Analysis of Community Health Worker Survey Data. Front Glob Womens Health 2022; 3:661000. [PMID: 35284909 PMCID: PMC8907823 DOI: 10.3389/fgwh.2022.661000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background The mixed-gender community health worker (CHW) program in Mozambique is a window into the different experiences that male and female CHWs may face in their work. The objective of this study is to investigate how gender influenced the experiences of community health workers using the PIERS on the Move (POM) mHealth app in Mozambique. Methods This is a secondary analysis by gender of health care workers involved in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial (NCT01911494). A structured survey with 10 open-ended questions was used to elicit CHW experiences using the POM app. Data collection took place in 2017 after completion of the CLIP trial. This analysis examined emergent themes to consider how experiences may have been shaped by health worker gender. Results Of the 43 CHWs who used the POM app, there were 31 (72%) women and 12 (28%) men. Gender differences emerged in descriptions of how using POM increased their value and respect by pregnant women and community members. Fifty-eight percent of female CHWs (18/31) said that POM positively influenced their status in the community in comparison to 33% of their male counterparts (4/12). While the small sample sizes, particularly of male CHWs who used POM, preclude conclusions, these findings were supported by qualitative results. Female CHWs tended to elaborate more about community perceptions of their increased value and status as health care providers than male CHWs. Conclusion CHWs work within existing gender norms. While gender norms are perceived to support the comfort of women to speak to another woman about their maternal and child health issues, gender norms also work against female CHWs as their professionalism may be questioned more than for their male counterparts. CHW's narratives suggested that the mHealth intervention was valued beyond the technology itself because it also added symbolic clinical value and demonstrated a tangible investment in their professional capacities, which may have been especially appreciated by the female CHWs.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Helena Boene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Laura A. Magee
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Beth A. Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Beth A. Payne
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Perveen S, Lassi ZS, Mahmood MA, Perry HB, Laurence C. Application of primary healthcare principles in national community health worker programmes in low-income and middle-income countries: a scoping review. BMJ Open 2022; 12:e051940. [PMID: 35110314 PMCID: PMC8811559 DOI: 10.1136/bmjopen-2021-051940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 01/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs). DESIGN Scoping review. DATA SOURCES A systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases. ELIGIBILITY CRITERIA The review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings. DATA EXTRACTION AND SYNTHESIS We reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme's objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review. RESULTS From 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident. CONCLUSION The implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.
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Affiliation(s)
- Shagufta Perveen
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Zohra S Lassi
- Robinson Research Institute, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mohammad Afzal Mahmood
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Henry B Perry
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Caroline Laurence
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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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.
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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
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Joshi U, Naslund JA, Anand A, Tugnawat D, Vishwakarma R, Bhan A, Patel V, Lu C. Assessing costs of developing a digital program for training community health workers to deliver treatment for depression: A case study in rural India. Psychiatry Res 2022; 307:114299. [PMID: 34871874 PMCID: PMC8730743 DOI: 10.1016/j.psychres.2021.114299] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/29/2021] [Accepted: 11/19/2021] [Indexed: 01/03/2023]
Abstract
Digital technology has emerged as a promising approach for training and building capacity of community health workers in low-income and middle-income countries (LMICs). Little is known about the cost of developing digital training programs in LMICs, which hinders the adoption, implementation, and scaling up of the programs in routine primary care settings. This study assessed the costs of developing a digital program for training community health workers to deliver a psychological treatment for depression in a rural district of Madhya Pradesh, India. We developed survey instruments to document required resources in development, including involved personnel (their roles, responsibilities, time spent, and salaries or payments), information technologies (e.g., smartphones, software programs), and infrastructure-related costs (e.g., vehicle, office space, utilities). Costs were estimated from an accounting perspective. Over a 10-month developmental period, the total costs were 208,814 USD, with the largest portion on human resources (61%, with 14% on management and supervision), followed by information technologies (33%), and infrastructure-related costs (6%). These findings could inform policymakers in LMICs on costs of developing online-training programs, which will be especially useful during the COVID-19 pandemic.
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Affiliation(s)
| | - John A. Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | | | | | - Vikram Patel
- Sangath, Bhopal, Madhya Pradesh, India,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Chunling Lu
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
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Shanthosh J, Durbach A, Joshi R. Charting the Rights of Community Health Workers in India: The Next Frontier of Universal Health Coverage. Health Hum Rights 2021; 23:225-238. [PMID: 34966238 PMCID: PMC8694295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Community health workers (CHWs) have the capacity to bring essential health services to under-resourced communities. Globally, CHWs have made significant contributions to poverty alleviation, increased food security, and reductions in health inequalities. India's one million accredited social health activists (ASHAs), the largest cohort of CHWs in the world, have been credited with increasing the rate of institutional deliveries and the uptake of vaccinations. ASHAs operate at the margins of health systems and the formal health workforce, often due to misperceptions of their skills and discrimination based on gender, socioeconomic status, education, and rurality. The "voluntary" nature of their work can entrench their precarious status, which is characterized by a lack of access to employment rights, adequate remuneration, and institutional support. This article argues that the prioritization of the labor rights of CHWs in the design and implementation of the World Health Organization's 2018 Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes can serve to ensure safe working conditions and freedom from discrimination, coercion, and violence. It further argues that the resultant enhancement and protection of CHWs' rights and long-term security provides an essential pathway for harnessing their potential to transform universal health coverage.
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Affiliation(s)
- Janani Shanthosh
- Research fellow at the George Institute for Global Health, and academic lead of the Health and Human Rights Programme at the Australian Human Rights Institute, University of New South Wales, Australia
| | - Andrea Durbach
- Emeritus professor in the Faculty of Law, University of New South Wales Sydney, and former director of the Australian Human Rights Centre (now Institute), Australia
| | - Rohina Joshi
- Associate professor in the Faculty of Medicine, University of New South Wales Sydney, and Head of the Global Health Workforce Program at the George Institute for Global Health, Australia.,Please address correspondence to Rohina Joshi.
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Closser S, Shekhawat SS. The family context of ASHA and Anganwadi work in rural Rajasthan: Gender and labour in CHW programmes. Glob Public Health 2021; 17:1973-1985. [PMID: 34432611 DOI: 10.1080/17441692.2021.1970206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Across the literature on CHWs globally, the role of CHWs' families remains largely unexplored. This article focuses on ASHAs and Anganwadi Workers in a town in rural Rajasthan, India. We interviewed all twenty ASHAs and Anganwadi Workers in this town, and ten of their families; we also conducted participant observation in Anganwadi Centers, health centres, and family settings. ASHA and Anganwadi work was in high demand, despite being low paying, because of an overall lack of jobs for educated women. Every aspect of CHW work, from recruitment to selection to training to the number of hours spent on the job, was heavily determined by families. Women's mobility, income, and workload was tied up in family structures. ASHA and Anganwadi Work increased the mobility and autonomy of the women who held those jobs in significant ways. But mostly, women stayed in these extremely low paying jobs because they and their families hoped that one day they would become permanent jobs with salaries and benefits. By providing honourable work, and keeping the idea of permanent employment in view but always just out of reach, the ASHA and Anganwadi programmes both exploited and strengthened gendered inequalities in the rural Rajasthani labour market.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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16
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Rajbangshi PR, Nambiar D, Srivastava A. Community health workers: challenges and vulnerabilities of Accredited Social Health Activists working in conflict-affected settings in the state of Assam, India. BMC Health Serv Res 2021; 21:829. [PMID: 34404397 PMCID: PMC8369326 DOI: 10.1186/s12913-021-06780-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/08/2021] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION It is well acknowledged that India's community health workers known as Accredited Social Health Activists (ASHA) are the bedrock of its health system. Many ASHAs are currently working in fragile and conflict-affected settings. No efforts have yet been made to understand the challenges and vulnerabilities of these female workers. This paper seeks to address this gap by bringing attention to the situation of ASHAs working in the fragile and conflict settings and how conflict impacts them and their work. METHODS Qualitative fieldwork was undertaken in four conflict-affected villages in two conflict-affected districts -Kokrajhar and Karbi Anglong of Assam state situated in the North-East region of India. Detailed account of four ASHAs serving roughly 4000 people is presented. Data transliterated into English were analysed by authors by developing a codebook using grounded theory and thematic organisation of codes. RESULTS ASHAs reported facing challenges in ensuring access to health services during and immediately after outbreaks of conflict. They experienced difficulty in arranging transport and breakdown of services at remote health facilities. Their physical safety and security were at risk during episodes of conflict. ASHAs reported hostile attitudes of the communities they served due to the breakdown of social relations, trauma due to displacement, and loss of family members, particularly their husbands. CONCLUSIONS Conflict must be recognised as an important context within which community health workers operate, with greater policy focus and research devoted to understanding and addressing the barriers they face as workers and as persons affected by conflict.
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Affiliation(s)
- Preety R Rajbangshi
- The George Institute for Global Health, 311-312, Third Floor, Elegance Tower,Plot No.8,Jasola District Centre, 10025, New Delhi, India.
| | - Devaki Nambiar
- The George Institute for Global Health, 311-312, Third Floor, Elegance Tower,Plot No.8,Jasola District Centre, 10025, New Delhi, India
- Faculty of Medicine, University of New South Wales, Kensington, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Aradhana Srivastava
- World Food Programme, A-2, Poorvi Marg, Block A, Vasant Vihar, 110057, New Delhi, India
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17
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Yasobant S, Bruchhausen W, Saxena D, Memon FZ, Falkenberg T. Health System Contact and Awareness of Zoonotic Diseases: Can it Serve as One Health Entry Point in the Urban Community of Ahmedabad, India? THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:259-269. [PMID: 34211346 PMCID: PMC8223553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
One Health (OH) is emphasized globally to tackle the (re)emerging issues at the human-animal-ecosystem interface. However, the low awareness about zoonoses remain a challenge in global south, thus this study documented the health system contact and its effect on the awareness level of zoonoses in the urban community of Ahmedabad, India. A community-based household survey was conducted between October 2018 and July 2019. A total of 460 households (HHs) were surveyed from two zones and 23 wards of the city through cluster sampling. A structured, pilot-tested, and researcher-administered questionnaire in the vernacular language was used to collect the information on demographic details, socio-economic details, health-seeking behavior for both the humans and their animals, human and animal health system contact details and the participants' awareness on selected zoonotic diseases based on the prioritization (rabies, brucellosis, swine flu, and bird flu). Out of 460 surveyed households, 69% of HHs and 59% of HHs had a health system contact to the human and animal health system respectively at the community level. There are multiple health workers active on the community level that could potentially serve as One Health liaisons. The investigation of the knowledge and awareness level of selected zoonotic diseases revealed that 58.5%, 47.6%, and 4.6% know about rabies, swine and/or bird flu, and brucellosis, respectively. The mixed-effect linear regression model indicates that there is no significant effect on the zoonotic disease awareness score with the human health system contact; however, a minimal positive effect with the animal health system contact was evident.
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Affiliation(s)
- Sandul Yasobant
- Center for Development Research (ZEF), University of
Bonn, Bonn, Germany,Global Health, Institute for Hygiene and Public Health
(IHPH), University Hospital Bonn, Bonn, Germany,To whom all correspondence should be addressed:
Sandul Yasobant, MPH, PhD, Center for Development Research (ZEF), Genscherallee
3, 53113 Bonn, Germany; Tel: +91-98761357331,
; ORCID iD: https://orcid.org/0000-0003-1770-8745
| | - Walter Bruchhausen
- Center for Development Research (ZEF), University of
Bonn, Bonn, Germany,Global Health, Institute for Hygiene and Public Health
(IHPH), University Hospital Bonn, Bonn, Germany
| | - Deepak Saxena
- Indian Institute of Public Health Gandhinagar (IIPHG),
Gandhinagar, India,Jawaharlal Nehru Medical College, Datta Meghe Institute
of Medical Sciences, Wardha, India
| | | | - Timo Falkenberg
- Center for Development Research (ZEF), University of
Bonn, Bonn, Germany,GeoHealth Centre, Institute for Hygiene and Public
Health (IHPH), University Hospital Bonn, Bonn, Germany
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18
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Schaaf M, Warthin C, Freedman L, Topp SM. The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability. BMJ Glob Health 2021; 5:bmjgh-2020-002296. [PMID: 32546585 PMCID: PMC7299037 DOI: 10.1136/bmjgh-2020-002296] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/04/2022] Open
Abstract
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.
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Affiliation(s)
| | - Caitlin Warthin
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lynn Freedman
- Averting Maternal Death and Disability, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
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19
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Rammohan A, Goli S, Saroj SK, Jaleel CPA. Does engagement with frontline health workers improve maternal and child healthcare utilisation and outcomes in India? HUMAN RESOURCES FOR HEALTH 2021; 19:45. [PMID: 33794920 PMCID: PMC8017836 DOI: 10.1186/s12960-021-00592-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Poor Maternal and Child Health (MCH) outcomes pose challenges to India's ability to attain Goal-3 of the Sustainable Development Goals (SDGs). The government of India strengthened the existing network of frontline health workers (FHWs), under its National Rural Health Mission in 2005 and subsequent National Urban Health Mission in 2013 as a strategy to mitigate the shortage of skilled health workers and to provide affordable healthcare services. However, there is a lack of robust national-level empirical analysis on the role of maternal engagement with FHWs in influencing the level of maternal and child health care utilisation and child health outcomes in India. METHODS Using data from the nationally representative Indian National Family Health Survey (NFHS) 2015-2016, this paper aims to investigate the intensity of engagement of FHWs with married women of child-bearing age (15-49 years), its influence on utilisation of maternal and child healthcare services, and child health outcomes. Our empirical analyses use multivariate regression analyses, focusing on five maternal and child health indicators: antenatal care visits (ANC) (4 or > 4 times), institutional delivery, full-immunisation of children, postnatal care (PNC) (within 2 days of delivery), and child survival. RESULTS Our analysis finds that maternal engagement with FHWs is statistically significant and a positive predictor of maternal and child health care utilisation, and child survival. Further, the level of engagement with FHWs is particularly important for women from economically poor households. Our robustness checks across sub-samples of women who delivered only in public health institutions and those from rural areas provides an additional confidence in our main results. CONCLUSIONS From a policy perspective, our findings highlight that strengthening the network of FHWs in the areas where they are in shortage which can help in further improving the utilisation of maternal and child healthcare services, and health outcomes. Also, the role of FHWs in the government health system needs to be enhanced by improving skills, working environment, and greater financial incentives.
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Affiliation(s)
- Anu Rammohan
- The University of Western Australia (M251), Crawley, WA, Australia
| | - Srinivas Goli
- The University of Western Australia (M251), Crawley, WA, Australia.
- Jawaharlal Nehru University, New Delhi, India.
- Australia India Institute, UWA Public Policy Institute, University of Western Australia, Crawley, WA, Australia.
| | | | - C P Abdul Jaleel
- UNICEF National Centre of Excellence and Advanced Research on Diets, Lady Irwin College, University of Delhi, New Delhi, India
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20
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Chase LE, Gurung D, Shrestha P, Rumba S. Gendering psychosocial care: risks and opportunities for global mental health. Lancet Psychiatry 2021; 8:267-269. [PMID: 33333065 DOI: 10.1016/s2215-0366(20)30483-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Liana E Chase
- Department of Anthropology, Durham University, Durham DH1 3LE, UK.
| | - Dristy Gurung
- Department of Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Parbati Shrestha
- Clinical Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
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21
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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.
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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
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22
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Gupta M, Rahman A, Dutta NC, Hossain MS, Nambiar D, Parveen S, Ivers R, Jagnoor J. Impact of a rural drowning reduction programme in Bangladesh on gender equity, norms and behaviour: a mixed-method analysis. BMJ Open 2020; 10:e041065. [PMID: 33262192 PMCID: PMC7709509 DOI: 10.1136/bmjopen-2020-041065] [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] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Community-based health programmes implemented in low-income and middle-income countries impact community gender norms and roles and relationships, which in turn affect individuals' health outcomes. Programmes should measure their effects on gender norms, roles and relationships in the communities in which they operate to respond to unexpected health consequences. We conducted a gender analysis on a drowning reduction programme in rural Bangladesh to identify its impacts on gendered roles and behaviours in the community. DESIGN A mixed-method approach was used. Quantitative programme monitoring data were analysed to assess gender differences in participation and engagement. A qualitative approach using interviews, focus group discussions and observations with purposively selected programme implementing staff and participants aimed at finding explanations for quantitative findings and additional impacts of the programme on gender in the community. The analysis was conducted using Family Health International 360's Gender Integration Framework, which identifies both internal (norms) and external (behaviours) effects. RESULTS Fewer girls (n=5030) participated in swimming classes than boys (n=6425) due to cultural restrictions and involvement in domestic work. Women were not hired in leadership roles in the implementing organisation due to lower transportation access and their perceived ability to conduct labour-intensive activities. However, communities become more accepting of local women's mobility and employment due to their engagement as swim instructors. Women swim instructors were more satisfied with the pay and part-time nature of the work as men were able to earn more elsewhere. Menstruation management was ignored as all supervisory staff were men. CONCLUSIONS Systematised strategies are required to ensure equal participation of girls and enable equitable prevention outcomes. Within the implementing organisation, programmatic changes will support gender transformation, such as ensuring women's mobility and engagement in leadership roles. Strategies to combat perceptions that lower paying part time work is more suitable for women than men may be considered.
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Affiliation(s)
- Medhavi Gupta
- Injury Division, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Aminur Rahman
- Centre for Injury Prevention and Research Bangladesh, Dhaka, Bangladesh
| | | | | | - Devaki Nambiar
- The George Institute for Global Health India, New Delhi, Delhi, India
| | - Samina Parveen
- The George Institute for Global Health India, New Delhi, Delhi, India
| | - Rebecca Ivers
- School of Public Health and Community Medicine, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
| | - Jagnoor Jagnoor
- The George Institute for Global Health India, New Delhi, Delhi, India
- School of Public Health and Community Medicine, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
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23
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Betron M, Thapa A, Amatya R, Thapa K, Arlotti-Parish E, Schuster A, Bhattarai J, Limbu S, Chiweshe MT, Rishal P, Dhital R. Should female community health volunteers (FCHVs) facilitate a response to gender-based violence (GBV)? A mixed methods exploratory study in Mangalsen, Nepal. Glob Public Health 2020; 16:1604-1617. [PMID: 33186506 DOI: 10.1080/17441692.2020.1839929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ABSTRACTAs part of a multisectoral response to gender-based violence (GBV), Nepal is testing the feasibility of having female community health volunteers (FCHVs) play a formal role in identifying GBV survivors and referring them to specialised services at health facilities. This study followed 116 FHCVs in Mangalsen municipality who attended a one-day orientation on GBV. Over the following year, data were collected from knowledge and attitude assessments of FCHVs, focus group discussions with FCHVs, and members of Mothers' Groups for Health. Most Significant Change stories were collected from FCHVs, in-depth interviews with stakeholders, and service statistics. Results show that the FCHVs' knowledge increased, attitudes changed, and confidence in addressing GBV grew. During the study period, FCHVs identified 1,253 GBV survivors and referred 221 of them to health facilities. In addition to assisting GBV survivors, FCHVs worked to prevent GBV by mediating conflicts and curbing harmful practices such as menstrual isolation. Stakeholders viewed FCHVs as a sustainable resource for identifying and referring GBV survivors to services, while women trusted them and looked to them for help. Results show that, with proper training and safety mechanisms, FCHVs can raise community awareness about GBV, facilitate support for survivors, and potentially help prevent harmful practices.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Poonam Rishal
- Dhulikhel Hospital, Kathmandu University Hospital, Kathmandu, Nepal
| | - Rolina Dhital
- Health Action and Research Lazimpat, Kathmandu, Nepal
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24
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Wahid SS, Munar W, Das S, Gupta M, Darmstadt GL. 'Our village is dependent on us. That's why we can't leave our work'. Characterizing mechanisms of motivation to perform among Accredited Social Health Activists (ASHA) in Bihar. Health Policy Plan 2020; 35:58-66. [PMID: 31670772 DOI: 10.1093/heapol/czz131] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2019] [Indexed: 12/30/2022] Open
Abstract
Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs' intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs' intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar's ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs' motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme's performance.
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Affiliation(s)
- Syed S Wahid
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, NW, Washington, DC 20052, USA
| | - Wolfgang Munar
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave, NW, Washington, DC 20052, USA
| | - Sharmila Das
- Purple Audacity Research and Innovation, Sector 12 A, Dwarka Building, Delhi 110075, India
| | - Mahima Gupta
- Purple Audacity Research and Innovation, Sector 12 A, Dwarka Building, Delhi 110075, India
| | - Gary L Darmstadt
- Department of Paediatrics, Centre for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, USA
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26
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Muke SS, Tugnawat D, Joshi U, Anand A, Khan A, Shrivastava R, Singh A, Restivo JL, Bhan A, Patel V, Naslund JA. Digital Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression in Primary Care in India: Findings from a Randomized Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6368. [PMID: 32883018 PMCID: PMC7503742 DOI: 10.3390/ijerph17176368] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/23/2020] [Accepted: 08/28/2020] [Indexed: 12/13/2022]
Abstract
Introduction: Task sharing holds promise for scaling up depression care in countries such as India, yet requires training large numbers of non-specialist health workers. This pilot trial evaluated the feasibility and acceptability of a digital program for training non-specialist health workers to deliver a brief psychological treatment for depression. Methods: Participants were non-specialist health workers recruited from primary care facilities in Sehore, a rural district in Madhya Pradesh, India. A three-arm randomized controlled trial design was used, comparing digital training alone (DGT) to digital training with remote support (DGT+), and conventional face-to-face training. The primary outcome was the feasibility and acceptability of digital training programs. Preliminary effectiveness was explored as changes in competency outcomes, assessed using a self-reported measure covering the specific knowledge and skills required to deliver the brief psychological treatment for depression. Outcomes were collected at pre-training and post-training. Results: Of 42 non-specialist health workers randomized to the training programs, 36 including 10 (72%) in face-to-face, 12 (86%) in DGT, and 14 (100%) in DGT+ arms started the training. Among these participants, 27 (64%) completed the training, with 8 (57%) in face-to-face, 8 (57%) in DGT, and 11 (79%) in DGT+. The addition of remote telephone support appeared to improve completion rates for DGT+ participants. The competency outcome improved across all groups, with no significant between-group differences. However, face-to-face and DGT+ participants showed greater improvement compared to DGT alone. There were numerous technical challenges with the digital training program such as poor connectivity, smartphone app not loading, and difficulty navigating the course content-issues that were further emphasized in follow-up focus group discussions with participants. Feedback and recommendations collected from participants informed further modifications and refinements to the training programs in preparation for a forthcoming large-scale effectiveness trial. Conclusions: This study adds to mounting efforts aimed at leveraging digital technology to increase the availability of evidence-based mental health services in primary care settings in low-resource settings.
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Affiliation(s)
- Shital S. Muke
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Deepak Tugnawat
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Udita Joshi
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Aditya Anand
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Azaz Khan
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Ritu Shrivastava
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Abhishek Singh
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Juliana L. Restivo
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; (J.L.R.); (V.P.)
| | - Anant Bhan
- Sangath, 120 Deepak Society, Chuna Bhatti, Kolar Road, Bhopal 462016, India; (S.S.M.); (D.T.); (U.J.); (A.A.); (A.K.); (R.S.); (A.S.); (A.B.)
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; (J.L.R.); (V.P.)
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - John A. Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; (J.L.R.); (V.P.)
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Design and Development of a Digital Program for Training Non-Specialist Health Workers to Deliver an Evidence-Based Psychological Treatment for Depression in Primary Care in India. ACTA ACUST UNITED AC 2020; 5:402-415. [PMID: 34150992 DOI: 10.1007/s41347-020-00154-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Digital technologies hold promise for building capacity of non-specialist health workers towards scaling up depression care in low-resource settings. The purpose of this study was to describe the systematic approach to designing a digital program for training non-specialist health workers to deliver an evidence-based brief psychological treatment for depression, called the Healthy Activity Program, in primary care in rural India. Methods The design and development of the training program involved 5 steps: 1) develop program blueprint; 2) create instructional content; 3) digitize content for a smartphone app; 4) develop a platform for uploading and hosting the digital content; and 5) user-testing and refinements to ensure program functioning. This was followed by field-testing and focus group discussions with non-specialist health workers recruited from primary care facilities in Madhya Pradesh, India, to inform further modifications and improvements to the digital training program. Results Training program development occurred over 12-months, and the final digital training consisted of 16 modules with videos, role-plays, and digital content tailored to the local culture and context. Focus group discussions with 19 non-specialist health workers generated three key action items and modifications to the digital training in response to participant feedback: 1) addressing technical challenges by making the digital content available offline; 2) account for low digital literacy by including a comprehensive orientation session about navigating the smartphone app; and 3) addition of remote coaching to support participants in completing the training. Conclusions This study illustrates a step-wise approach to combine evidence-based content with iterative feedback from stakeholders to develop a digital training program tailored to the context in a low-resource setting. Further research is needed to validate this approach and to evaluate the effectiveness of the final modified digital training program, while considering whether this approach can be adopted and replicated in other settings.
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Gupta M, Rahman A, Dutta NC, Nambiar D, Ivers R, Jagnoor J. Opportunities for gender transformative approaches in a community-based drowning reduction program in Bangladesh. Int J Equity Health 2020; 19:108. [PMID: 32611417 PMCID: PMC7329458 DOI: 10.1186/s12939-020-01226-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/22/2020] [Indexed: 12/02/2022] Open
Abstract
Background Community-based programs in rural low-and middle-income country settings are well-placed to conduct gender transformative activities that aid program sustainability and catalyse wider social change, such as reducing gender inequities that in turn improve health outcomes. The Anchal program is a drowning prevention intervention for children aged 1–5 years old in rural Bangladesh. It provides community crèche-based supervision delivered by local trained paid-female volunteers. We aimed to identify the influence of the Anchal program on gender norms and behaviours in the community context, and the effects these had on program delivery and men and women’s outcomes. Methods Qualitative in-depth interviews, focus group discussions and observations were conducted with program beneficiaries and providers. Gender outcomes were analysed using FHI 360’s Gender Integration Framework. Results The Anchal program was found to be a gender accommodating program as it catered for communities’ gender-based roles and constraints but did not actively seek to change underlying beliefs, perceptions and norms that led to these. The program in some cases enhanced the independence and status of female community staff. This changed perceptions of communities towards acceptable levels of physical mobility and community involvement for women. Conversely, gender affected program delivery by reducing the ability of female supervisory staff to engage with male community leaders. The double burden of wage and household labour carried by local female staff also limited performance and progression. Gender-based constraints on staff performance, attrition and community engagement affected efficiency of program delivery and sustainability. Conclusions The Anchal program both adapted to and shaped community gender norms and roles. The program has well-established relationships in the community and can be leveraged to implement gender transformative activities to improve gender-based equity. Health programs can broaden their impacts and target social determinants of health like gender equity to increase program sustainability and promote equitable health outcomes.
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Affiliation(s)
- M Gupta
- The George Institute for Global Health Australia, University of New South Wales, Sydney, Australia
| | - A Rahman
- Centre for Injury Prevention and Research, House B 162, Road 23, New DOHS, Mohakhali, Dhaka, 1206, Bangladesh
| | - N C Dutta
- Centre for Injury Prevention and Research, House B 162, Road 23, New DOHS, Mohakhali, Dhaka, 1206, Bangladesh
| | - D Nambiar
- The George Institute for Global Health India, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India
| | - R Ivers
- School of Public Health and Medicine, Faculty of Medicine, UNSW Australia, Samuels Building, Botany Street, Kensington, 2052, Australia
| | - J Jagnoor
- The George Institute for Global Health India, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India.
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Ruiz-Mirazo K, Shirt-Ediss B, Escribano-Cabeza M, Moreno A. The Construction of Biological 'Inter-Identity' as the Outcome of a Complex Process of Protocell Development in Prebiotic Evolution. Front Physiol 2020; 11:530. [PMID: 32547413 PMCID: PMC7269143 DOI: 10.3389/fphys.2020.00530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/29/2020] [Indexed: 11/25/2022] Open
Abstract
The concept of identity is used both (i) to distinguish a system as a particular material entity that is conserved as such in a given environment (token-identity: i.e., identity as permanence or endurance over time), and (ii) to relate a system with other members of a set (type-identity: i.e., identity as an equivalence relationship). Biological systems are characterized, in a minimal and universal sense, by a highly complex and dynamic, far-from-equilibrium organization of very diverse molecular components and transformation processes (i.e., 'genetically instructed cellular metabolisms') that maintain themselves in constant interaction with their corresponding environments, including other systems of similar nature. More precisely, all living entities depend on a deeply convoluted organization of molecules and processes (a naturalized von Neumann constructor architecture) that subsumes, in the form of current individuals (autonomous cells), a history of ecological and evolutionary interactions (across cell populations). So one can defend, on those grounds, that living beings have an identity of their own from both approximations: (i) and (ii). These transversal and trans-generational dimensions of biological phenomena, which unfold together with the actual process of biogenesis, must be carefully considered in order to understand the intricacies and metabolic robustness of the first living cells, their underlying uniformity (i.e., their common biochemical core) and the eradication of previous -or alternative- forms of complex natural phenomena. Therefore, a comprehensive approach to the origins of life requires conjugating the actual properties of the developing complex individuals (fusing and dividing protocells, at various stages) with other, population-level features, linked to their collective-evolutionary behavior, under much wider and longer-term parameters. On these lines, we will argue that life, in its most basic sense, here on Earth or anywhere else, demands crossing a high complexity threshold and that the concept of 'inter-identity' can help us realize the different aspects involved in the process. The article concludes by pointing out some of the challenges ahead if we are to integrate the corresponding explanatory frameworks, physiological and evolutionary, in the hope that a more general theory of biology is on its way.
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Affiliation(s)
- Kepa Ruiz-Mirazo
- Department of Logic and Philosophy of Science, University of the Basque Country, San Sebastian, Spain
- Biofisika Institute (CSIC, UPV-EHU), Leioa, Spain
| | - Ben Shirt-Ediss
- Interdisciplinary Computing and Complex BioSystems Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Miguel Escribano-Cabeza
- Department of Logic and Philosophy of Science, University of the Basque Country, San Sebastian, Spain
| | - Alvaro Moreno
- Department of Logic and Philosophy of Science, University of the Basque Country, San Sebastian, Spain
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Steege R, Taegtmeyer M, Ndima S, Give C, Sidat M, Ferrão C, Theobald S. Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique's community health workforce. HUMAN RESOURCES FOR HEALTH 2020; 18:37. [PMID: 32448359 PMCID: PMC7245854 DOI: 10.1186/s12960-020-00476-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 05/05/2020] [Indexed: 05/23/2023]
Abstract
BACKGROUND Mozambique's community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). The Government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique. METHODS We employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise the findings. FINDINGS In-depth interviews (n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband's consent. Training programmes outside of the community were viewed positively as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. CONCLUSION Gender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo Province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.
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Affiliation(s)
- Rosalind Steege
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom.
| | - Miriam Taegtmeyer
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom
| | - Sozinho Ndima
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Celso Give
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Mohsin Sidat
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Clara Ferrão
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Sally Theobald
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom
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Gupta M, Zwi AB, Jagnoor J. Opportunities for the development of drowning interventions in West Bengal, India: a review of policy and government programs. BMC Public Health 2020; 20:704. [PMID: 32414356 PMCID: PMC7229618 DOI: 10.1186/s12889-020-08868-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/07/2020] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Four million people living in the Indian Sundarbans region in the state of West Bengal face a particularly high risk of drowning due to rurality, presence of open water, lack of accessible health systems and poor infrastructure. Although the World Health Organization has identified several interventions that may prevent drowning in rural low-and middle-income country contexts, none are currently implemented in this region. This study aims to conduct contextual policy analysis for the development of a drowning program. Implementation of a drowning program should consider leveraging existing structures and resources, as interventions that build on policy targets or government programs are more likely to be sustainable and scalable. METHODS A detailed content review of national and state policy (West Bengal) was conducted to identify policy principles and/or specific government programs that may be leveraged for drowning interventions. The enablers and barriers of these programs as well as their implementation reach were assessed through a systematic literature review. Identified policies and programs were also assessed to understand how they catered for underserved groups and their implications for equity. RESULTS Three programs were identified that may be leveraged for the implementation of drowning interventions such as supervised childcare, provision of home-based barriers, swim and rescue skills training and community first responder training: the Integrated Child Development Scheme (ICDS), Self-Help Group (SHG) and Accredited Social Health Activist (ASHA) programs. All three had high coverage in West Bengal and considered underserved groups such as women and rural populations. Possible barriers to using these programs were poor government monitoring, inadequate resource provision and overburdening of community-based workers. CONCLUSIONS This is the first systematic analysis of both policy content and execution of government programs to provide comprehensive insights into possible implementation strategies for a health intervention, in this case drowning. Programs targeting specific health outcomes should consider interventions outside of the health sector that address social determinants of health. This may enable the program to better align with relevant government agendas and increase sustainability.
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Affiliation(s)
- M Gupta
- The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia.
| | - A B Zwi
- Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, UNSW Australia, Morven Brown Building, Kensington, 2052, Australia
| | - J Jagnoor
- Injury Division, The George Institute for Global Health, New Delhi, 110025, India
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Agarwal S, Sripad P, Johnson C, Kirk K, Bellows B, Ana J, Blaser V, Kumar MB, Buchholz K, Casseus A, Chen N, Dini HSF, Deussom RH, Jacobstein D, Kintu R, Kureshy N, Meoli L, Otiso L, Pakenham-Walsh N, Zambruni JP, Raghavan M, Schwarz R, Townsend J, Varpilah B, Weiss W, Warren CE. A conceptual framework for measuring community health workforce performance within primary health care systems. HUMAN RESOURCES FOR HEALTH 2019; 17:86. [PMID: 31747947 PMCID: PMC6868857 DOI: 10.1186/s12960-019-0422-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/24/2019] [Indexed: 05/23/2023]
Abstract
BACKGROUND With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. METHODS A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. RESULTS Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. CONCLUSIONS Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.
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Affiliation(s)
- Smisha Agarwal
- Population Council, Washington, DC USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | | | | | | | - Joseph Ana
- Healthcare Information For All (HIFA), Oxford, UK
| | | | - Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | | | | | | | | | | | | | - Lilian Otiso
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Brigham and Women’s Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA USA
| | | | | | - William Weiss
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
- USAID, Washington, DC USA
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Abdel-All M, Abimbola S, Praveen D, Joshi R. What do Accredited Social Health Activists need to provide comprehensive care that incorporates non-communicable diseases? Findings from a qualitative study in Andhra Pradesh, India. HUMAN RESOURCES FOR HEALTH 2019; 17:73. [PMID: 31640722 PMCID: PMC6805300 DOI: 10.1186/s12960-019-0418-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/20/2019] [Indexed: 05/30/2023]
Abstract
BACKGROUND The Indian National Program for Cardiovascular Disease, Diabetes, Cancer and Stroke (NPCDCS) was introduced to provide non-communicable disease (NCD) care through primary healthcare teams including Accredited Social Health Activists (ASHAs). Since ASHAs are being deployed to provide NCD care on top of their regular work for the first time, there is a need to understand the current capacity and challenges faced by them. METHODS A desktop review of NPCDCS and ASHA policy documents was conducted. This was followed by group discussions with ASHAs, in-depth interviews with their supervisors and medical officers and group discussions with community members in Guntur, Andhra Pradesh, India. The multi-stakeholder data were analysed for themes related to needs, capacity, and challenges of ASHAs in providing NCD services. RESULTS This study identified three key themes-first, ASHAs are unrecognised as part of the formal NPCDCS service delivery team. Second, they are overburdened, since they deliver several NPCDCS activities without receiving training or remuneration. Third, they aspire to be formally recognised as employees of the health system. However, ASHAs are enthusiastic about the services they provide and remain an essential link between the health system and the community. CONCLUSION ASHAs play a key role in providing comprehensive and culturally appropriate care to communities; however, they are unrecognised and overburdened and aspire to be part of the health system. ASHAs have the potential to deliver a broad range of services, if supported by the health system appropriately. TRIAL REGISTRATION The study was registered with "Clinical Trials Registry - India" (identifier CTRI/2018/03/012425 ).
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Affiliation(s)
- Marwa Abdel-All
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.
| | - Seye Abimbola
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - D Praveen
- The George Institute for Global Health, University of New South Wales, New Delhi, India
| | - Rohina Joshi
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, New Delhi, India
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Jain M, Pandian J, Samuel C, Singh S, Kamra D, Kate M. Multicomponent Short-Term Training of ASHAs for Stroke Risk Factor Management in Rural India. J Neurosci Rural Pract 2019; 10:592-598. [PMID: 31844374 PMCID: PMC6908455 DOI: 10.1055/s-0039-3399396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Stroke is one of the leading causes of disability-adjusted life years and may be the leading cause of death in rural regions in India. We aim to train the ASHAs (Accredited Social Health activist) for nonpharmacological management of risk factors for secondary stroke prevention in rural India. We tested the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management. Objectives To test the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management. Materials and Methods This study is part of the ASSIST trial (Training ASHA to Assist in Secondary Stroke Prevention in Rural Population). The study design is quasi-experimental (pretest and posttest). Culturally appropriate and pragmatic training material was developed by the study team. Three focused group training sessions were conducted in Sidhwan Bet and Pakhowal blocks of Ludhiana district, Punjab. Results A total of 274 ASHAs from 164 villages with mean ± SD age of 39.5 ± 7.6 years participated in the three training sessions. The perceived knowledge of stroke risk factors and blood pressure assessment was 67.5 ± 18.3% and 84.4 ± 16.7%, respectively. The objective baseline knowledge about stroke prevention and management among ASHAs was lower 58.7 ± 19.7% compared with perceived knowledge ( p = 0.04). This increased to 82.5 ± 16.36% ( p < 0.001) after the mop-up training after a mean of 191 days. More than 30% increment was seen in knowledge about the stroke symptoms (35.9%, p < 0.001), avoiding opium after stroke for treatment (39.5%, p < 0.001), causes of stroke (53.3%, p < 0.001), modifiable risk factors for stroke (45.4%, p < 0.001), and lifestyle modifications for stroke prevention (42.1%, p < 0.001). Conclusions Focused group training can help enhance the knowledge of ASHAs about stroke prevention and management. ASHAs are also able to retain this complex multicomponent knowledge over a 6-month period. ASHA may be able to partake in reducing the secondary stroke burden in rural India.
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Affiliation(s)
- Maneeta Jain
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Clarence Samuel
- Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India
| | - Shavinder Singh
- Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India
| | - Deepshikha Kamra
- Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India
| | - Mahesh Kate
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
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Scott K, George AS, Ved RR. Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective. Health Res Policy Syst 2019; 17:29. [PMID: 30909926 PMCID: PMC6434894 DOI: 10.1186/s12961-019-0427-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale. METHODS We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework. RESULTS A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results. CONCLUSION Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.
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Affiliation(s)
| | - Asha S. George
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, 7535 South Africa
| | - Rajani R. Ved
- National Health Systems Resource Centre, New Delhi, India
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