The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria

The impact of home-based management of malaria on clinical outcomes in sub-Saharan African populations: a systematic review and meta-analysis

BACKGROUND

Malaria remains a significant cause of morbidity and mortality globally and continues to disproportionately afflict the African population. We aimed to evaluate the effect of home management of malaria intervention on health outcomes.

METHODS

In our systematic review and meta-analysis, six databases (Pubmed, Cochrane CENTRAL, EMBASE, CAB Abstracts and Global Health, CINAHL Complete, and BIOSIS) were searched for studies of home management of malaria from inception until November 15, 2023. We included before-after studies, observational studies, and randomised controlled trials of home management intervention delivered in community settings. The primary outcomes were malaria mortality and all-cause mortality. The risk of bias in individual observational studies was assessed using the ROBINS-I tool, whilst randomised controlled trials were judged using a revised Cochrane risk of bias tool and cluster-randomised controlled trials were evaluated using an adapted Cochrane risk of bias tool for cluster-randomised trials. We computed risk ratios with accompanying 95% confidence intervals for health-related outcomes reported in the studies and subsequently pooled the results by using a random-effects model (DerSimonian-Laird method).

RESULTS

We identified 1203 citations through database and hand searches, from which 56 articles from 47 studies encompassing 234,002 participants were included in the systematic review. All studies were conducted in people living in sub-Saharan Africa and were rated to have a low or moderate risk of bias. Pooled analyses showed that mortality rates due to malaria (RR = 0.40, 95% CI = 0.29-0.54, P = 0.00001, I2 = 0%) and all-cause mortality rates (RR = 0.62, 95% CI = 0.53-0.72, P = 0.00001, I2 = 0%) were significantly lower among participants receiving home management intervention compared to the control group. However, in children under 5 years of age, there was no significant difference in mortality rates before and after implementation of home management of malaria. In terms of secondary outcomes, home management of malaria was associated with a reduction in the risk of febrile episodes (RR = 1.27, 95% CI = 1.09-1.47, P = 0.002, I2 = 97%) and higher effective rates of antimalarial treatments (RR = 2.72, 95% CI = 1.90-3.88, P < 0.00001, I2 = 96%) compared to standard care. Home malaria management combined with intermittent preventive treatment showed a significantly lower incidence risk of malaria than home management intervention that exclusively provided treatment to individuals with febrile illness suggestive of malaria. The risks for adverse events were found to be similar for home management intervention using different antimalarial drugs. Cost-effectiveness findings depicted that home malaria management merited special preferential scale-up.

CONCLUSIONS

Home management of malaria intervention was associated with significant reductions in malaria mortality and all-cause mortality. The intervention could help decrease health and economic burden attributable to malaria. Further clinical studies are warranted to enable more meaningful interpretations with regard to wide-scale implementation of the intervention, settings of differing transmission intensity, and new antimalarial drugs.

Recruitment and selection of community health workers in Iran; a thematic analysis

BACKGROUND

In Iran, community health workers (CHWs) are selected and employed according to the instructions of the Ministry of Health (MOH). The present study aimed to investigate the views of different stakeholders regarding the selection criteria, as well as the competency of CHWs.

METHODS

This study was conducted using a qualitative thematic analysis in Golestan Province, Iran. Data were collected using semi-structured interviews with managers, supervisors, CHWs, and common people in 2021. The interviews were recorded and then transcribed. To extract key themes, the six-step Brown model was used, which involved becoming acquainted with the data, meaningful organization of transcripts, extracting primary open codes, searching for themes in an iterative approach, theme extraction, defining themes, and preparing a report. The relationships between codes and sub-themes and themes were represented using ATLAS.ti version 8.

RESULTS

Data saturation was achieved after interviewing 22 people. The extracted data included 340 open codes, two main sub-themes of "CHW effectiveness" and "CHW sustainability", and three main themes of "criteria for employing competent people", "barriers to employing competent people", and "identifying the barriers to employing competent people", according to the MOH instructions.

CONCLUSION

In the present study, local hiring was one of the major challenges in the competency-based selection of CHWs. One of the most repeated codes was expanding the local hiring concept and its requirements. Since different regions of Iran have different climatic, economic, cultural, and social conditions, the selection and hiring criteria for CHWs should be tailored to the needs of the community.

Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review

BACKGROUND

Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations.

METHODS

We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively.

RESULTS

Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively.

CONCLUSION

Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.

Community health workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria-A qualitative study

BACKGROUND

Community Health Workers are globally recognised as crucial members of healthcare systems in low and middle-income countries, but their role and experience during COVID-19 is not well-understood. This study aimed to explore factors that influence CHWs' ability and willingness to work in the COVID-19 pandemic in Lagos.

DESIGN

A generic qualitative study exploring Community Health Workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria.

METHODS

15 semi-structured, in-depth, video interviews were conducted with Community Health Workers purposively sampled across seven of Lagos' Local Government Areas with the highest COVID-19 burden. Interviews explored Community Health Workers' attitudes towards COVID-19, its management, and their experiences working in Lagos. Data was analysed thematically using the framework method.

RESULTS

Three main themes were identified. 1. Influences on ability to undertake COVID-19 Role: Trust and COVID-19 knowledge were found to aid Community Health Workers in their work. However, challenges included exhaustion due to an increased workload, public misconceptions about COVID-19, stigmatisation of COVID-19 patients, delayed access to care and lack of transportation. 2. Influences on willingness to work in COVID-19 Role: Community Health Workers' perceptions of COVID-19, attitudes towards responsibility for COVID-19 risk at work, commitment and faith appeared to increase willingness to work. 3. Suggested Improvements: Financial incentives, provision of adequate personal protective equipment, transportation, and increasing staff numbers were seen as potential strategies to address many of the challenges faced.

CONCLUSION

Despite Community Health Workers being committed to their role, they have faced many challenges during the COVID-19 pandemic in Nigeria. Changes to their working environment may make their role during disease outbreaks more fulfilling and sustainable. International input is required to enhance Nigeria's policies and infrastructure to better support Community Health Workers during both current and future outbreaks.

Fidelity of implementation of the building bridges mentoring intervention to prevent violence among youth in low income settings

Violence among youth is a major health and safety burden globally. There is a dearth in the development and evaluation of targeted interventions that addresses the multi-faceted nature of youth violence to ensure effectiveness and replicability. This study aims to systematically evaluate the fidelity of implementation of the Building Bridges Mentoring intervention that focuses on the prevention of youth violence in two low-income communities in South Africa. This study employed a mixed methods concurrent triangulation design. Qualitative data were analysed using deductive thematic analysis, and quantitative data using descriptive statistics and T-tests. The results indicate that for all the intervention components, implementation fidelity (i.e. adherence, exposure, quality of programme delivery, and participant responsiveness) was generally moderate to high, suggesting a 'good' implementation of the programme in the real world. Evaluating the fidelity of implementation is vital to obtain a comprehensive insight into whether an intervention was implemented according to its design, and to verify and validate the findings and outcomes, and accord credibility and integrity of the study.