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Tizifa TA, Kabaghe AN, McCann RS, Gowelo S, Malenga T, Nkhata RM, Chapeta Y, Nkhono W, Kadama A, Takken W, Phiri KS, van Vugt M, van den Berg H, Manda-Taylor L. Assessing the implementation fidelity, feasibility, and sustainability of community-based house improvement for malaria control in southern Malawi: a mixed-methods study. BMC Public Health 2024; 24:951. [PMID: 38566043 PMCID: PMC10988826 DOI: 10.1186/s12889-024-18401-4] [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: 09/18/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Despite significant success in the fight against malaria over the past two decades, malaria control programmes rely on only two insecticidal methods: indoor residual spraying and insecticidal-treated nets. House improvement (HI) can complement these interventions by reducing human-mosquito contact, thereby reinforcing the gains in disease reduction. This study assessed the implementation fidelity, which is the assessment of how closely an intervention aligns with its intended design, feasibility, and sustainability of community-led HI in southern Malawi. METHODS The study, conducted in 22 villages (2730 households), employed a mixed-methods approach. Implementation fidelity was assessed using a modified framework, with longitudinal surveys collecting data on HI coverage indicators. Quantitative analysis, employing descriptive statistics, evaluated the adherence to HI implementation. Qualitative data came from in-depth interviews, key informant interviews, and focus groups involving project beneficiaries and implementers. Qualitative data were analysed using content analysis guided by the implementation fidelity model to explore facilitators, challenges, and factors affecting intervention feasibility. RESULTS The results show that HI was implemented as planned. There was good adherence to the intended community-led HI design; however, the adherence could have been higher but gradually declined over time. In terms of intervention implementation, 74% of houses had attempted to have eaves closed in 2016-17 and 2017-18, compared to 70% in 2018-19. In 2016-17, 42% of houses had all four sides of the eaves closed, compared to 33% in 2018-19. Approximately 72% of houses were screened with gauze wire in 2016-17, compared to 57% in 2018-19. High costs, supply shortages, labour demands, volunteers' poor living conditions and adverse weather were reported to hinder the ideal HI implementation. Overall, the community described community-led HI as feasible and could be sustained by addressing these socioeconomic and contextual challenges. CONCLUSION Our study found that although HI was initially implemented as planned, its fidelity declined over time. Using trained volunteers facilitated the fidelity and feasibility of implementing the intervention. A combination of rigorous community education, consistent training, information, education and communication, and intervention modifications may be necessary to address the challenges and enhance the intervention's fidelity, feasibility, and sustainability.
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Affiliation(s)
- Tinashe A Tizifa
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, University of Amsterdam, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands.
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
| | - Alinune N Kabaghe
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Robert S McCann
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Laboratory of Entomology, Wageningen University & Research, Wageningen, The Netherlands
- Centre for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, USA
| | - Steven Gowelo
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Laboratory of Entomology, Wageningen University & Research, Wageningen, The Netherlands
| | - Tumaini Malenga
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- National TB and Leprosy Elimination Programme, Ministry of Health, Lilongwe, Malawi
| | - Richard M Nkhata
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yankho Chapeta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Biological Sciences Department, Mzuzu University, Mzuzu, Malawi
| | - William Nkhono
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Asante Kadama
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Willem Takken
- Laboratory of Entomology, Wageningen University & Research, Wageningen, The Netherlands
| | - Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michele van Vugt
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, University of Amsterdam, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Henk van den Berg
- Laboratory of Entomology, Wageningen University & Research, Wageningen, The Netherlands
| | - Lucinda Manda-Taylor
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Tesfa H, Getahun FA, Alemu YM. Motivation and associated factors of health development army in the implementation of health extension packages in Northwest Ethiopia: a cross-sectional study. BMJ Open 2024; 14:e077060. [PMID: 38521525 PMCID: PMC10961543 DOI: 10.1136/bmjopen-2023-077060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Health development army is a network of women volunteers organised to promote health and prevent disease through community empowerment and participation. OBJECTIVE To assess the level of motivation and associated factors of the health development army in the implementation of health extension packages in Northwest Ethiopia. DESIGN Data were from a community-based cross-sectional study. SETTING This study was conducted in Mecha district, Northwest Ethiopia. The district is located around 30 km from Bahir Dar, the capital city of Amhara National Regional State, Ethiopia. PARTICIPANTS A total of 624 health development army members were interviewed using a structured questionnaire from 20 April 2020 to 20 May 2020. OUTCOME MEASURES Motivation was assessed using a five-item Likert scale statement ranging from 1 to 5. Data were collected using a structured questionnaire and analysed using a binary logistic regression model. RESULTS The proportion of health development army members, who had motivation in the implementation of the health extension package, was 47.8% (95% CI (43.90 to 51.80)). The odds of having motivation were higher among health development army members who lived in urban areas ((adjusted OR, AOR 2.47; 95% CI (1.21 to 5.03)), were less than 30 years ((AOR 2.42; 95% CI (1.22 to 4.78)), had more than 4 years work experience ((AOR 4.72; 95% CI (2.54 to 8.76)), had high intrinsic job satisfaction ((AOR 2.31; 95% CI (1.51 to 3.55)), had good community support ((AOR 2.46; 95% CI (1.34 to 4.51)), received supportive supervision ((AOR 1.85; 95% CI (1.24 to 2.77)) and were recognised for their efforts ((AOR 1.52; 95% CI (1.01 to 2.30)). CONCLUSION The proportion of motivation among health development army members was low. To increase the motivation of health development army members in the implementation of the health extension package, measures or strategies may consider targeting members who live in rural areas, are older than 30 years, have less than 4 years of work experience, report low job satisfaction, have low community support, do not have supportive supervision and are not recognised.
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Affiliation(s)
- Hiwot Tesfa
- College of Medicine and Health Sciences, Department of Public Health, Injibara University, Injibara, Ethiopia
| | - Fentie Ambaw Getahun
- College of Medicine and Health Sciences, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Yihun Mulugeta Alemu
- College of Medicine and Health Sciences, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
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Kletter M, Harris B, Connolly E, Namathanga C, Nhlema B, Makungwa H, Chabwera B, Phiri B, Brown C. Mixed method evaluation of a learning from excellence programme for community health workers in Neno, Malawi. BMC Health Serv Res 2024; 24:355. [PMID: 38504273 PMCID: PMC10953074 DOI: 10.1186/s12913-024-10686-w] [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: 01/10/2023] [Accepted: 02/05/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Community Health Workers (CHWs) play an essential role in linking communities to facility-based healthcare. However, CHW programmes have often been hampered by low levels of staff motivation, and new tools aimed at improving staff motivation and work environment are needed. One such intervention is the "Learning from Excellence" (LfE) programme. We aimed to assess feasibility, outputs, and impact of a co-designed LfE programme on CHW motivation, in Neno District. METHODS We conducted a convergent mixed-method evaluation of the LfE programme. Co-design of the programme and forms took place between October 2019 and January 2020. LfE forms submitted between September and November 2020 were analysed using descriptive statistics and memos summarising answers to the open-ended question. To investigate experiences with LfE we conducted in-depth semi-structured interviews with key stakeholders, CHWs, and site supervisors, which were analysed thematically. A pre-post intervention questionnaire was developed to assess the impact of the co-designed LfE intervention on CHW motivation and perceived supervision. Outcomes were triangulated into a logic model. RESULTS In total 555 LfE forms were submitted, with 34.4% of CHWs in Neno District submitting at least one LfE report. Four themes were identified in the interviews: LfE implementation processes, experience, consequences, and recommendations. A total of 50 CHWs participated in the questionnaire in January 2020 and 46 of them completed the questionnaire in December 2020. No statistically significant differences were identified between pre-and post-LfE measurements for both motivation (Site F: p = 0.86; Site G: p = 0.31) and perceived supervision (Site F: p = 0.95; Site G: p = 0.45). A logic model, explaining how the LfE programme could impact CHWs was developed. CONCLUSIONS Many CHWs participated in the LfE intervention between September 2020 and November 2020. LfE was welcomed by CHWs and stakeholders as it allowed them to appreciate excellent work in absence of other opportunities to do so. However, no statistically significant differences in CHW motivation and perceived supervision were identified. While the intervention was feasible in Neno District, we identified several barriers and facilitators for implementation. We developed a logic model to explain contextual factors, and mechanisms that could lead to LfE outcomes for CHWs in Neno District. The developed logic model can be used by those designing and implementing interventions like LfE for health workers.
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Affiliation(s)
- Maartje Kletter
- The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - Bronwyn Harris
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | | | | | - Henry Makungwa
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | - Benson Chabwera
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | - Benson Phiri
- Partners In Health/Abwenzi Pa Za Umoyo, Neno, PO Box 56, Malawi
| | - Celia Brown
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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Ndambo MK, Aron MB, Makungwa H, Munyaneza F, Nhlema B, Connolly E. Perspectives of community and facility stakeholders on community health workers in rural Malawi. Afr J Prim Health Care Fam Med 2024; 16:e1-e11. [PMID: 38426769 PMCID: PMC10913143 DOI: 10.4102/phcfm.v16i1.4199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household-level CHW services, in remote areas, to understand CHW's role in community-based PHC. AIM To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community-based PHC in Neno District. SETTING The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa. METHODS We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change. RESULTS Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community-based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community-based PHC. CONCLUSION Community health workers enrich community-based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health-seeking behaviours.Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.
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Ingenhoff R, Munana R, Weswa I, Gaal J, Sekitoleko I, Mutabazi H, Bodnar BE, Rabin TL, Siddharthan T, Kalyesubula R, Knauf F, Nalwadda CK. Principles for task shifting hypertension and diabetes screening and referral: a qualitative study exploring patient, community health worker and healthcare professional perceptions in rural Uganda. BMC Public Health 2023; 23:881. [PMID: 37173687 PMCID: PMC10176286 DOI: 10.1186/s12889-023-15704-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND A shortage of healthcare workers in low- and middle-income countries (LMICs) combined with a rising burden of non-communicable diseases (NCDs) like hypertension and diabetes mellitus has resulted in increasing gaps in care delivery for NCDs. As community health workers (CHWs) often play an established role in LMIC healthcare systems, these programs could be leveraged to strengthen healthcare access. The objective of this study was to explore perceptions of task shifting screening and referral for hypertension and diabetes to CHWs in rural Uganda. METHODS This qualitative, exploratory study was conducted in August 2021 among patients, CHWs and healthcare professionals. Through 24 in-depth interviews and ten focus group discussions, we investigated perceptions of task shifting to CHWs in the screening and referral of NCDs in Nakaseke, rural Uganda. This study employed a holistic approach targeting stakeholders involved in the implementation of task shifting programs. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically guided by the framework method. RESULTS Analysis identified elements likely to be required for successful program implementation in this context. Fundamental drivers of CHW programs included structured supervision, patients' access to care through CHWs, community involvement, remuneration and facilitation, as well as building CHW knowledge and skills through training. Additional enablers comprised specific CHW characteristics such as confidence, commitment and motivation, as well as social relations and empathy. Lastly, socioemotional aspects such as trust, virtuous behavior, recognition in the community, and the presence of mutual respect were reported to be critical to the success of task shifting programs. CONCLUSION CHWs are perceived as a useful resource when task shifting NCD screening and referral for hypertension and diabetes from facility-based healthcare workers. Before implementation of a task shifting program, it is essential to consider the multiple layers of needs portrayed in this study. This ensures a successful program that overcomes community concerns and may serve as guidance to implement task shifting in similar settings.
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Affiliation(s)
- Rebecca Ingenhoff
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Richard Munana
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University College of Health Sciences, Makerere University, Kampala, Uganda
- African Community Center for Social Sustainability, Nakaseke, Uganda
| | - Ivan Weswa
- African Community Center for Social Sustainability, Nakaseke, Uganda
| | - Julia Gaal
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Isaac Sekitoleko
- MRC/UVRI and LSHTM Uganda Research Unit, Kampala, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Hillary Mutabazi
- African Community Center for Social Sustainability, Nakaseke, Uganda
| | - Benjamin E Bodnar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy L Rabin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Trishul Siddharthan
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Coral Gables, USA
| | - Robert Kalyesubula
- African Community Center for Social Sustainability, Nakaseke, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Physiology, Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Christine K Nalwadda
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University College of Health Sciences, Makerere University, Kampala, Uganda
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Ejigu Y, Abera N, Haileselassie W, Berhanu N, Haile BT, Nigatu F, Tewfik N, Kiflie Y, Medhin G, Walelign F, Demissie M, Tigabu S, Taddesse D, Dadi TL, Teklu A. Motivation and job satisfaction of community health workers in Ethiopia: a mixed-methods approach. HUMAN RESOURCES FOR HEALTH 2023; 21:35. [PMID: 37127695 PMCID: PMC10152586 DOI: 10.1186/s12960-023-00818-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Ethiopia has been providing health care to its rural population since 2004 using female Community Health Workers called Health Extension Workers (HEWs). The HEWs are credited with several achievements in improving the country's health indicators. However, information about the HEWs' motivation and job satisfaction is limited. The aim of this study was to assess the HEWs' motivation and job satisfaction, as well as the factors that influence them. METHODS A mixed-methods study was nested within a national health extension program assessment conducted from March 01 to May 31, 2019. A structured questionnaire which looked at motivation and satisfaction with Likert type single-question and multiple-item measures was used to collect quantitative data from 584 HEWs. Focus group discussion and in-depth interviews were used to gather qualitative data. Means and percentages were used to descriptively summarize important variables. Linear regression was used to identify factors associated with job satisfaction. The qualitative data was analysed thematically. RESULTS Overall, 48.6% of HEWs were satisfied with their job, with a mean score of 2.5 out of 4.0. The result showed a high level of satisfaction with autonomy (72%), relationships with co-workers (67%), and recognition (56%). Low level of satisfaction was linked to pay and benefits (13%), opportunities for promotion (29%), and education (34%). Regression analysis showed that HEWs in the age category of 30 years and older had lower satisfaction scores as compared to HEWs in the age category of 18-24 years (adjusted β = - 7.71, 95% CI: - 14.42, - 0.99). The qualitative result revealed that desire to help their community, recognition or respect gained from the community, and achievement were the major motivating factors. In contrast, inadequate pay and benefit, limited education and career advancement opportunities, workload, work environment, limited supportive supervision, and absence of opportunity to change workplace were the demotivating factors. CONCLUSIONS The overall job satisfaction of HEWs was low; extrinsic factors, such as inadequate pay, limited education and career advancement opportunities were the major sources of demotivation. Policy makers and human resource managers should revise their human resource policies and guidelines to address the main sources of low level of job satisfaction and demotivation.
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Affiliation(s)
- Yohannes Ejigu
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia.
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia.
| | - Netsanet Abera
- School of Public Health, Hawassa University, Hawassa, Ethiopia
| | | | - Negalign Berhanu
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | - Biniyam Tadesse Haile
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | - Frehiwot Nigatu
- International Institute for Primary Health Care, Addis Ababa, Ethiopia
| | - Nurhan Tewfik
- International Institute for Primary Health Care, Addis Ababa, Ethiopia
| | - Yibeltal Kiflie
- Faculty of Public Health, Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fasil Walelign
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
- School of Public Health, Wollo University, Dessie, Ethiopia
| | - Mekdes Demissie
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
| | - Setegn Tigabu
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
| | - Daniel Taddesse
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
| | - Tegene Legese Dadi
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
- School of Public Health, Hawassa University, Hawassa, Ethiopia
| | - Alula Teklu
- Monitoring, Evaluation, Research, and Quality Improvement (MERQ) PLC, Ethiopia Office, Addis Ababa, Ethiopia
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Kok MO, Terra T, Tweheyo R, van der Hoeven M, Ponce MC, van Furth MT, Rutebemberwa E. Using telehealth to support community health workers in Uganda during COVID-19: a mixed-method study. BMC Health Serv Res 2023; 23:284. [PMID: 36973681 PMCID: PMC10040915 DOI: 10.1186/s12913-023-09217-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/23/2023] [Indexed: 03/28/2023] Open
Abstract
Background At the onset of the COVID-19 pandemic, a local consortium in Uganda set up a telehealth approach that aimed to educate 3,500 Community Health Workers (CHW) in rural areas about COVID-19, help them identify, refer and care for potential COVID-19 cases, and support them in continuing their regular community health work. The aim of this study was to assess the functioning of the telehealth approach that was set up to support CHWs during the COVID-19 pandemic. Methods For this mixed-method study, we combined analysis of routine consultation data from the call-center, 24 interviews with key-informants and two surveys of 150 CHWs. Data were analyzed using constant comparative method of analysis. Results Between March 2020 and June 2021, a total of 35,553 consultations took place via the call center. While the CHWs made extensive use of the call center, they rarely asked for support for potential Covid-19 cases. According to the CHWs, there were no signs that people in their communities were suffering from severe health problems due to COVID-19. People compared the lack of visible symptoms to diseases such as Ebola and were skeptical about the danger of COVID-19. At the same time, people in rural areas were afraid to report relevant symptoms and get tested for fear of being quarantined and stigmatized. The telehealth approach did prove useful for other purposes, such as supporting CHWs with their regular tasks and coordinating the supply of essential products. The health professionals at the call center supported CHWs in diagnosing, referring and treating patients and adhering to infection prevention and control practices. The CHWs felt more informed and less isolated, saying the support from the call center helped them to provide better care and improved the supply of medicine and other essential health products. Conclusions The telehealth approach, launched at the start of the COVID-19 pandemic, provided useful support to thousands of CHWs in rural communities in Uganda. The telehealth approach could be quickly set up and scaled up and offers a low cost strategy for providing useful and flexible support to CHWs in rural communities.
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Affiliation(s)
- Maarten Olivier Kok
- grid.6906.90000000092621349Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Tosca Terra
- Healthy Entrepreneurs Foundation, Kampala, Uganda
| | - Raymond Tweheyo
- grid.11194.3c0000 0004 0620 0548Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda
| | - Marinka van der Hoeven
- grid.16872.3a0000 0004 0435 165XAmsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Maiza Campos Ponce
- grid.16872.3a0000 0004 0435 165XAmsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Marceline Tutu van Furth
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Vrije Universiteit Amsterdam Infectious Diseases, Amsterdam, The Netherlands
| | - Elizeus Rutebemberwa
- grid.11194.3c0000 0004 0620 0548Department of Health Policy Planning and Management, Makerere University, Kampala, Uganda
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Pandya S, Hamal M, Abuya T, Kintu R, Mwanga D, Warren CE, Agarwal S. Understanding Factors That Support Community Health Worker Motivation, Job Satisfaction, and Performance in Three Ugandan Districts: Opportunities for Strengthening Uganda's Community Health Worker Program. Int J Health Policy Manag 2022; 11:2886-2894. [PMID: 35461208 PMCID: PMC10105203 DOI: 10.34172/ijhpm.2022.6219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 03/30/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Uganda's community health worker (CHW) program experiences several challenges related to the appropriate motivation, job satisfaction, and performance of the CHW workforce. This study aims to identify barriers in the effective implementation of financial and non-financial incentives to support CHWs and to strengthen Uganda's CHW program. METHODS The study was implemented in Uganda's Lira, Wakiso, and Mayuge districts in May 2019. Ten focus group discussions (FGDs) were held with 91 CHWs, 17 in-depth interviews (IDIs) were held with CHW supervisors, and 7 IDIs were held with policy-level stakeholders. Participants included stakeholders from both the Ugandan government and non-governmental organizations (NGOs). Utilizing a thematic approach, themes around motivation, job satisfaction, incentive preferences, and CHW relationships with the community, healthcare facilities, and government were analyzed. RESULTS CHWs identified a range of factors that contributed to their motivation or demotivation. Non-monetary factors included recognition from the health system and community, access to transportation, methods for identification as a healthcare worker, provision of working tools, and training opportunities. Monetary factors included access to monthly stipends, transportation-related refunds, and timely payment systems to reduce refund delays to CHWs. Additionally, CHWs indicated wanting to be considered for recruitment into the now-halted rollout of a salaried CHW cadre, given the provision of payment. CONCLUSION It is imperative to consider how to best support the current CHW program prior to the introduction of new cadres, as it can serve to exacerbate tensions between cadres and further undermine provision of community health. Providing a harmonized, balanced, and uniform combination of both monetary incentives with non-monetary incentives is vital for effective CHW programs.
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Affiliation(s)
- Shivani Pandya
- Department of International Health, the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mukesh Hamal
- Department of International Health, the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | - Smisha Agarwal
- Department of International Health, the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Hämmerli P, Moukam AD, Wisniak A, Sormani J, Vassilakos P, Kenfack B, Petignat P, Schmidt NC. "My motivation was to save": a qualitative study exploring factors influencing motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. Reprod Health 2022; 19:133. [PMID: 35668427 PMCID: PMC9167909 DOI: 10.1186/s12978-022-01420-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cervical cancer is a major public health issue among women in Cameroon and uptake of screening programs remains a challenge in many low- and middle-income countries. Community healthcare workers can play an important role in promoting cervical cancer services. This study aimed to explore factors affecting the motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. Methods A qualitative approach including 11 in-depth individual interviews with community healthcare workers was used. The interviews were audio-recorded, transcribed and coded using thematic analysis assisted by ATLAS.ti software. Results Four women and seven men aged between 21 and 77 years old were interviewed. Community healthcare workers had high motivation. Factors affecting motivation were divided into individual and environmental level, based on a theoretical framework. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Conclusions Key interventions to improve motivation among community healthcare workers include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport. Trial registration: Geneva Cantonal Ethics Committee on Human Research (No. 2017-01110) and the Cameroonian National Ethics Committee for Human Health Research (No. 2018/07/1083/CE/CNERSH/SP). Cervical cancer is the second leading cause of cancer-related death among women in Cameroon. This is mainly due to the absence of routine cervical cancer screening programs and the lack of treatment. However, even in case of availability of cervical cancer screening programs, barriers exist. Therefore, community healthcare workers have been involved successfully to increase the screening coverage. As retention of these actors remains a challenge, the main objective of this study was to identify key factors affecting their motivation aiming to suggest interventions to address motivational factors. 11 qualitative interviews with individual community healthcare workers were conducted at a cervical cancer screening program in Dschang, Cameroon. Motivation was generally high and affecting factors were divided into the individual and the environmental level. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Ongoing collaboration with community healthcare workers is beneficial for cervical cancer screening programs, and key interventions should therefore include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.
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Affiliation(s)
| | - Alida Datchoua Moukam
- Department of Gynaecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Ania Wisniak
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Jessica Sormani
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.,Geneva School of Health Sciences, HESSO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Gynaecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Patrick Petignat
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Nicole Christine Schmidt
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland. .,Faculty of Social Science, Catholic University of Applied Science, Preysingstr. 95, 81667, Munich, Germany.
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10
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Karim A, de Savigny D, Awor P, Cobos Muñoz D, Mäusezahl D, Kitoto Tshefu A, Ngaima JS, Enebeli U, Isiguzo C, Nsona H, Ogbonnaya I, Ngoy P, Alegbeleye A. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health 2022; 7:bmjgh-2022-008493. [PMID: 35772810 PMCID: PMC9247653 DOI: 10.1136/bmjgh-2022-008493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/30/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. Methods We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. Results The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. Conclusion The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.
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Affiliation(s)
- Aliya Karim
- University of Basel, Basel, Switzerland .,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Don de Savigny
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Cobos Muñoz
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Daniel Mäusezahl
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Jean Serge Ngaima
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ugo Enebeli
- Department of Community Medicine, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Chinwoke Isiguzo
- School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Society for Family Health Nigeria, Abuja, Nigeria
| | - Humphreys Nsona
- IMCI, Malawi Ministry of Health, Lilongwe, Central Region, Malawi
| | - Ikechi Ogbonnaya
- Department of Health, Planning, Research & Statistics, Federal Ministry of Health, Abuja, Federal Capital Territory, Nigeria
| | - Pascal Ngoy
- PROSANI, USAID, Washington, District of Columbia, USA
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11
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DMPA-SC stock: Cross-site trends by facility type. Contracept X 2022; 4:100075. [PMID: 35493973 PMCID: PMC9046645 DOI: 10.1016/j.conx.2022.100075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To measure trends in the supply of DMPA-SC in public and private health facilities and compare with other prominent modern methods. Study design We used repeated cross-sectional data from service-delivery-point surveys in six settings: Burkina Faso, Democratic Republic of Congo (Kinshasa and Kongo Central), Nigeria (Kano and Lagos), and Uganda, each with 3-5 rounds of data collected between 2016 and 2020. We analyzed trends in DMPA-SC availability using percent of service delivery points offering the method and percent experiencing stockouts; trends were compared with those for DMPA-IM, IUD, implants, and other short-acting methods, by facility type. Results All settings showed increased offering of DMPA-SC over time for both private and public facilities. Larger proportions of public facilities provided DMPA-SC compared to private facilities (66%–97% vs 16%–50% by 2019–2020). DMPA-SC was provided by fewer facilities than DMPA-IM (90%–100% public, 34%–69% private by 2019–2020), but comparable to implants (83%–100% public, 15%–52% private by 2019–2020) and IUDs (55%–91% public, 0%–44% private by 2019–2020). Trends of DMPA-SC stock varied by setting, with more consistent stock available in private facilities in the DRC and in public facilities in Burkina Faso and Nigeria. Uganda showed decreasing stock in public facilities but increasing stock in private facilities. Conclusion DMPA-SC availability has been increasing since its introduction in sub-Saharan Africa, yet significant gaps in stock exist. Countries should consider alternative distribution models to address these issues. Implications Our findings may help inform countries about the need to monitor DMPA-SC availability and to consider solutions that ensure contraceptive options are available to women who need them and disruptions to contraceptive use are minimized.
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12
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Tekle MG, Wolde HM, Medhin G, Teklu AM, Alemayehu YK, Gebre EG, Bekele F, Arora N. Understanding the factors affecting attrition and intention to leave of health extension workers: a mixed methods study in Ethiopia. HUMAN RESOURCES FOR HEALTH 2022; 20:20. [PMID: 35183209 PMCID: PMC8858524 DOI: 10.1186/s12960-022-00716-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 02/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The Health Extension Program (HEP) is Ethiopia's flagship community health program, launched in 2003. Health Extension Workers (HEWs) are key vehicles for the delivery of the HEP. While it is believed that there is high attrition among HEWs, the magnitude of or reasons for attrition is unknown. Their intention to leave their jobs in the next 5 years has also never been investigated on a national scale. This study aimed to assess the magnitude of, and factors affecting HEWs' attrition and intention to leave in Ethiopia. METHODS The study used mixed methods to address the research objectives. Using stratified random sampling and regions as strata, 85 districts from nine regions were randomly selected in Ethiopia. Within each study district, six kebeles (village clusters) were randomly selected, and all HEWs working in these kebeles were interviewed to capture their 5-year intention to leave. The study team developed a data-extraction tool for a rapid review of district-level documents covering the period June 30, 2004 through June 30, 2019 to gather their attrition figures. We used survival analysis to model attrition data and checked model goodness-of-fit using the Cox-Snell residual test. We additionally collected qualitative data from HEWs who had left their positions. RESULTS The attrition of HEWS over the lifespan of the HEP was 21.1% (95% CI 17.5-25.3%), and the median time to exit from HEWs workforce was 5.8 years. The incidence rate was 3.1% [95% CI 2.8-3.4]. The risk of attrition was lower amongst HEWs with level four certifications, with children, and among those working in urban settings. By contrast, HEWs who were not certified with a certificate of competency (COC), who were deployed after 2008, and those who were diploma/degree holders were more likely to exit the HEWs workforce. The magnitude of intention to leave was 39.5% (95% CI 32.5-47%) and the primary reasons to leave were low incentives, dearth of career development opportunities (50.8%), high workload (24.2%), and other psychosocial factors (25%). CONCLUSION Although the magnitude of attrition is not worryingly high, we see high magnitude in HEWs' intention to leave, indicating a dissatisfied workforce. Multiple factors have contributed to attrition and intention to leave, the prevalence of many of which can be reduced to fit the needs of this workforce and to retain them for the sustained delivery of primary healthcare in the country. Ensuring HEWs' job satisfaction is important and linked with their career development and potentially higher rates of retention.
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Affiliation(s)
| | - Habtamu Milkias Wolde
- Federal Ministry of Health, Addis Ababa, Ethiopia
- MERQ Consultant PLC, Addis Ababa, Ethiopia
| | | | | | | | - Esie Gebrewahd Gebre
- School of Geography and Environmental Studies, Haramaya University, Harar, Ethiopia
| | | | - Nikita Arora
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
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13
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Ndambo MK, Munyaneza F, Aron MB, Nhlema B, Connolly E. Qualitative assessment of community health workers' perspective on their motivation in community-based primary health care in rural Malawi. BMC Health Serv Res 2022; 22:179. [PMID: 35148772 PMCID: PMC8840069 DOI: 10.1186/s12913-022-07558-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities. METHODS We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March-April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose. RESULTS Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs. CONCLUSION This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can focus on enhancing motivational factors found in this study to improve the CHWs' experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.
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Affiliation(s)
| | - Fabien Munyaneza
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
| | - Moses Banda Aron
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
| | - Basimenye Nhlema
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi
| | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Blantyre, Malawi.,Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, USA
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14
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Deussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. Systematic review of performance-enhancing health worker supervision approaches in low- and middle-income countries. HUMAN RESOURCES FOR HEALTH 2022; 20:2. [PMID: 34991604 PMCID: PMC8733429 DOI: 10.1186/s12960-021-00692-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The strength of a health system-and ultimately the health of a population-depends to a large degree on health worker performance. However, insufficient support to build, manage and optimize human resources for health (HRH) in low- and middle-income countries (LMICs) results in inadequate health workforce performance, perpetuating health inequities and low-quality health services. METHODS The USAID-funded Human Resources for Health in 2030 Program (HRH2030) conducted a systematic review of studies documenting supervision enhancements and approaches that improved health worker performance to highlight components associated with these interventions' effectiveness. Structured by a conceptual framework to classify the inputs, processes, and results, the review assessed 57 supervision studies since 2010 in approximately 29 LMICs. RESULTS Of the successful supervision approaches described in the 57 studies reviewed, 44 were externally funded pilots, which is a limitation. Thirty focused on community health worker (CHW) programs. Health worker supervision was informed by health system data for 38 approaches (67%) and 22 approaches used continuous quality improvement (QI) (39%). Many successful approaches integrated digital supervision technologies (e.g., SmartPhones, mHealth applications) to support existing data systems and complement other health system activities. Few studies were adapted, scaled, or sustained, limiting reports of cost-effectiveness or impact. CONCLUSION Building on results from the review, to increase health worker supervision effectiveness we recommend to: integrate evidence-based, QI tools and processes; integrate digital supervision data into supervision processes; increase use of health system information and performance data when planning supervision visits to prioritize lowest-performing areas; scale and replicate successful models across service delivery areas and geographies; expand and institutionalize supervision to reach, prepare, protect, and support frontline health workers, especially during health emergencies; transition and sustain supervision efforts with domestic human and financial resources, including communities, for holistic workforce support. In conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.
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Affiliation(s)
- Rachel Deussom
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Doris Mwarey
- Human Resources for Health Consultant, Formerly With Chemonics International, PO Box 26432–00100, Nairobi, Kenya
| | - Mekdelawit Bayu
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Sarah S. Abdullah
- HRH2030 Program, Chemonics International, 1717 H Street NW, Washington, DC 20006 United States of America
| | - Rachel Marcus
- Office of Health Systems, Bureau for Global Health, United States Agency for International Development, 1300 Pennsylvania Avenue NW, Washington, DC 20004 United States of America
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15
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Roy S, Pandya S, Hossain MI, Abuya T, Warren CE, Mitra P, Rob U, Hossain S, Agarwal S. Beyond Institutionalization: Planning for Sustained Investments in Training, Supervision, and Support of Community Health Worker Programs in Bangladesh. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:765-776. [PMID: 34933974 PMCID: PMC8691870 DOI: 10.9745/ghsp-d-21-00156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022]
Abstract
Institutionalizing community health workers (CHWs) is insufficient for improving program quality. Governments must plan for sustained investments for salaries and benefits, as well as systems enabling adaptive management of the CHW cadres. Greater coordination is needed at the global level to pool and align donor investments to support the ecosystem underlying CHW programs. Introduction: Methods: Results: Discussion:
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Affiliation(s)
| | - Shivani Pandya
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Paloma Mitra
- Krieger School of Arts and Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Smisha Agarwal
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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16
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Musoke D, Atusingwize E, Ndejjo R, Ssemugabo C, Siebert P, Gibson L. Enhancing Performance and Sustainability of Community Health Worker Programs in Uganda: Lessons and Experiences From Stakeholders. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:855-868. [PMID: 34933981 PMCID: PMC8691894 DOI: 10.9745/ghsp-d-21-00260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/22/2021] [Indexed: 12/04/2022]
Abstract
We conducted a 1-day workshop—a unique opportunity to engage stakeholders at all levels of community health worker (CHW) program involvement—to discuss learned experiences and strategies to enhance and sustain the CHW program in Uganda. Background: Community health worker (CHW) programs in Uganda have contributed to improved health outcomes in recent years. However, opportunities for engaging the various stakeholders supporting CHW programs have been limited. This article presents workshop findings where several stakeholders shared their lessons and experiences that can enhance performance and sustainability of CHW programs in Uganda. Methods: We collected qualitative data from stakeholders from government, private, and community organizations, as well as CHWs, involved in CHW programs in Uganda during a 1-day workshop. The workshop involved plenary presentations and group discussions on critical aspects of CHW programs. All proceedings from the workshop were audio-recorded, transcribed, and analyzed by thematic content analysis. Results: Four major themes emerged from the workshop: lessons learned in implementing CHW programs, challenges affecting CHW programs, performance of CHWs, and ensuring sustainability of CHW programs. Key lessons learned related to 3 main subthemes: capacity building and use of technology, supervision and motivation, and stakeholder engagement and collaboration. Challenges affecting CHW programs identified included poor coordination, fragmented data collection systems, high program expectations, inadequate support mechanisms, and high dropout rates. Mechanisms for improving the performance of CHWs emphasized the need to: strengthen recruitment, training, and retention strategies; improve motivation; streamline coordination mechanisms; and develop and strengthen community health policies. The sustainability of CHW programs requires institutionalization; sustainable funding; economic empowerment of CHWs; local ownership; and a strengthened research agenda. Conclusion: To improve the performance and sustainability of CHWs programs, stakeholders such as policy makers and implementing partners need to consider CHW needs, existing structures and policies, as well as local support.
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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.
| | - Edwinah Atusingwize
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Ssemugabo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Penelope Siebert
- School of Social Sciences, Nottingham Trent University, Nottingham, United Kingdom
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, United Kingdom
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Zheng J, Williams-Livingston A, Danavall N, Ervin C, McCray G. Online High School Community Health Worker Curriculum: Key Strategies of Transforming, Engagement, and Implementation. Front Public Health 2021; 9:667840. [PMID: 34760858 PMCID: PMC8573088 DOI: 10.3389/fpubh.2021.667840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Ample research evidence has demonstrated that Community Health Worker (CHW) programs are a cost-effective, culturally integrated, and impactful way to improve community health. Although most existing CHW programs recruit adults as CHWs, high school students, with their intellectual readiness and intimate community knowledge, also have great potential to be engaged as CHWs that impact community health. With this potential in mind, the High School Community Health Worker Curriculum (HSCHW), for face-to-face training, was created in 2016 at Morehouse School of Medicine (MSM) as an innovative solution to improve community health in underserved, urban neighborhoods. Sixteen Metro Atlanta high school students participated in the program's first cohort. The face-to-face HSCHW training program received very positive feedback from the students and community partners involved. Additionally, during the inaugural training, the program received more than 150 nationwide inquiries about an opportunity to either participate in the program or replicate its curriculum. Hence, in 2018, a corresponding online curriculum was created to meet these needs. The online HSCHW curriculum covers the roles and competencies described in the CHW Core Consensus (C3) Project and focuses on developing high school students' critical thinking, decision-making, and communication skills. As of February 2021, 346 high school community health workers have participated in this online curriculum. Purpose: This paper reports on the research study of the critical processes and strategies of transforming, engaging, and implementing the online HSCHW curriculum. Method: The project team conducted the research study to identify the key strategies to transform the face-to-face HSCHW curriculum, the engagement strategies embedded in the online curriculum's content development, and, ultimately, the curriculum's outcomes. Altogether, this mixed-method study analyzed and reported on the learning outcomes of 265 students', in tandem with 17 high school students' focused-group interviews and responses to online surveys. Results: The results showed that integrating instructional design processes is critical for the online curriculum's success. “Interestingness,” the latent concept embedded in the online HSCHW curriculum, engages high school students in learning about complex CHW skills, through digital content and activities. Furthermore, the successful implementation of the program and its student learning outcomes was assured by integrating the online curriculum with local schools and community resources, training the local community and school “trainers” to facilitate the curriculum online, and providing ongoing coaching support from the program team. Impacts: This paper provides a research report on the key strategies and processes of creating and implementing an online CHW curriculum for high school students. Its findings will inform future endeavors to develop an online CHW curriculum for lifelong learners and increase training effectiveness. The online HSCHW curriculum increases the national capacity of community health workers, whose work will increase community engagement and health equity. The curriculum also empowers high school students to acquire health knowledge that can bridge the educational gap between health knowledge acquisition and health knowledge application. Additionally, the online HSCHW curriculum presents a concrete example of leveraging digital platforms to teach complex public health competencies to young adults who can positively impact community health.
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Affiliation(s)
- Jinjie Zheng
- Department of Medical Education, Morehouse School of Medicine, Atlanta, GA, United States
| | | | - N'Dieye Danavall
- Office of Digital Learning, Morehouse School of Medicine, Atlanta, GA, United States
| | - Christopher Ervin
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA, United States
| | - Gail McCray
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, United States
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Parray AA, Dash S, Ullah MIK, Inam ZM, Kaufman S. Female Community Health Workers and Health System Navigation in a Conflict Zone: The Case of Afghanistan. Front Public Health 2021; 9:704811. [PMID: 34458226 PMCID: PMC8385435 DOI: 10.3389/fpubh.2021.704811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Afghanistan ranked 171st among 188 countries in the Gender Inequality Index of 2011 and has only 16% of its women participating in the labor force. The country has been mired in violence for decades which has resulted in the destruction of the social infrastructure including the health sector. Recently, Afghanistan has deployed community health workers (CHW) who make up majority of the health workforce in the remote areas of this country. This paper aims to bring the plight of the CHWs to the forefront of discussion and shed light on the challenges they face as they attempt to bring basic healthcare to people living in a conflict zone. The paper discusses the motivations of Afghani women to become CHWs, their status in the community and within the health system, the threatening situations under which they operate, and the challenges they face as working women in a deeply patriarchal society within a conflict zone. The paper argues that female CHWs should be provided proper accreditation for their work, should be allowed and encouraged to progress in their careers, and should be instilled at the heart of healthcare program planning because they have the field experience to make the most effective and community oriented programmatic decisions.
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Affiliation(s)
- Ateeb Ahmad Parray
- BRAC James P Grant School of Public Health, The Center of Excellence for Gender, Sexual and Reproductive Health and Rights, BRAC University, Dhaka, Bangladesh
| | - Sambit Dash
- Melaka Manipal Medical College, Department of Biochemistry, Manipal Academy of Higher Education, Manipal, India
| | - Md Imtiaz Khalil Ullah
- Advanced Intelligent Multidisciplinary Systems Lab, Department of Commuter Science Engineering, United International University, Dhaka, Bangladesh
| | - Zuhrat Mahfuza Inam
- BRAC James P Grant School of Public Health, The Center of Excellence for Gender, Sexual and Reproductive Health and Rights, BRAC University, Dhaka, Bangladesh
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Siya A, Mafigiri R, Migisha R, Kading RC. Uganda Mountain Community Health System-Perspectives and Capacities towards Emerging Infectious Disease Surveillance. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8562. [PMID: 34444315 PMCID: PMC8394296 DOI: 10.3390/ijerph18168562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 11/22/2022]
Abstract
In mountain communities like Sebei, Uganda, which are highly vulnerable to emerging and re-emerging infectious diseases, community-based surveillance plays an important role in the monitoring of public health hazards. In this survey, we explored capacities of village health teams (VHTs) in Sebei communities of Mount Elgon in undertaking surveillance tasks for emerging and re-emerging infectious diseases in the context of a changing climate. We used participatory epidemiology techniques to elucidate VHTs' perceptions on climate change and public health and assessed their capacities to conduct surveillance for emerging and re-emerging infectious diseases. Overall, VHTs perceived climate change to be occurring with wider impacts on public health. However, they had inadequate capacities in collecting surveillance data. The VHTs lacked transport to navigate through their communities and had insufficient capacities in using mobile phones for sending alerts. They did not engage in reporting other hazards related to the environment, wildlife, and domestic livestock that would accelerate infectious disease outbreaks. Records were not maintained for disease surveillance activities and the abilities of VHTs to analyze data were also limited. However, VHTs had access to platforms that could enable them to disseminate public health information. The VHTs thus need to be retooled to conduct their work effectively and efficiently through equipping them with adequate logistics and knowledge on collecting, storing, analyzing, and relaying data, which will improve infectious disease response and mitigation efforts.
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Affiliation(s)
- Aggrey Siya
- Department of Environmental Management, Makerere University, Kampala P.O. Box 7062, Uganda
- EcoHealth180, Kween District, Kapchorwa P.O. Box 250, Uganda
| | - Richardson Mafigiri
- Global Health Department, Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda;
| | - Richard Migisha
- Department of Physiology, Mbarara University of Science and Technology, Mbarara P.O. Box 1410, Uganda;
| | - Rebekah C. Kading
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA;
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Chowdhury R, McKague K, Krause H. How workers respond to social rewards: evidence from community health workers in Uganda. Health Policy Plan 2021; 36:239-248. [PMID: 33881139 PMCID: PMC8058949 DOI: 10.1093/heapol/czaa162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 11/14/2022] Open
Abstract
This paper investigates the effect of a non-financial incentive-a competitive annual award-on community health workers' (CHWs) performance, an issue in the public health literature that has not been explored to its potential. Combining data on a competitive social 'Best CHW' award with the monthly performance of 4050 CHWs across Uganda, we examined if introducing social recognition awards improved the performance of CHWs. In contrast to predominant explanations about the effect of awards on motivation, our first multilevel mixed-effect models found that an award within a branch (consisting of ∼30 CHWs) was negatively associated with the performance of the local peers of the winning CHW. Models focused on non-winning branch offices revealed two additional findings. First, a branch showed underperformance if a CHW from any of the three neighbouring branches won an award in the previous year, with average monthly performance scores dropping by 27 percentage points. Second, this negative association was seen only in the top 50th percentile of CHWs. The bottom 50th percentile of CHWs exhibited increased performance by 13 percentage points. These counter-intuitive results suggest that the negative response from high performers might be explained by their frustration of not winning the award or by emotions such as envy and jealousy generated by negative social comparisons. Our results suggest that more fine-grained examination of data pertaining to motivators for CHWs in low-income countries is needed. Motivational incentives like awards may need to be customized for higher- and lower-performing CHWs.
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Affiliation(s)
- Reajul Chowdhury
- Corresponding author. Agriculture and Consumer Economics, University of Illinois, Urbana – Champaign, 59 Mumford Hall, 1301 W. Gregory Drive Urbana, IL 61801, USA. E-mail:
| | - Kevin McKague
- Shannon School of Business, Cape Breton University, Sydney, Nova Scotia B1M 1A2, Canada
| | - Heather Krause
- Principal Data Scientist, Datassist, Toronto, ON M4Y 3E1, Canada
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21
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Abuya T, Mwanga D, Obadha M, Ndwiga C, Odwe G, Kavoo D, Wanyugu J, Warren C, Agarwal S. Incentive preferences for community health volunteers in Kenya: findings from a discrete choice experiment. BMJ Open 2021; 11:e048059. [PMID: 34226227 PMCID: PMC8258597 DOI: 10.1136/bmjopen-2020-048059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/26/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Community health volunteers (CHVs) play crucial roles in enabling access to healthcare at the community levels. Although CHVs are considered volunteers, programmes provide financial and non-financial incentives. However, there is limited evidence on which bundle of financial and non-financial incentives are most effective for their improved performance. METHODS We used a discrete choice experiment (DCE) to understand incentive preferences of CHVs with the aim to improve their motivation, performance and retention. Relevant incentive attributes were identified through qualitative interviews with CHVs and with their supervisors. We then deployed a nominal group technique to generate and rank preferred attributes among CHVs. We developed a DCE based on the five attributes and administered it to 211 CHVs in Kilifi and Bungoma counties in Kenya. We used mixed multinomial logit models to estimate the utility of each incentive attribute and calculated the trade-offs the CHWs were willing to make for a change in stipend. RESULTS Transport was considered the incentive attribute with most relative importance followed by tools of trade then monthly stipend. CHVs preferred job incentives that offered higher monthly stipends even though it was not the most important. They had negative preference for job incentives that provided award mechanisms for the best performing CHVs as compared with jobs that provided recognition at the community level and preferred job incentives that provided more tools of trade compared with those that provided limited tools. CONCLUSION A bundled incentive of both financial and non-financial packages is necessary to provide a conducive working environment for CHVs. The menu of options relevant for CHVs in Kenya include transport, tools of trade and monthly stipend. Policy decisions should be contextualised to include these attributes to facilitate CHW satisfaction and performance.
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Affiliation(s)
- Timothy Abuya
- Reproductive Health, Population Council, Nairobi, Kenya
| | - Daniel Mwanga
- Reproductive Health, Population Council, Nairobi, Kenya
| | - Melvin Obadha
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - George Odwe
- Reproductive Health, Population Council, Nairobi, Kenya
| | - Daniel Kavoo
- Division of Community Health Services, Minsitry of Health, Nairobi, Kenya
| | - John Wanyugu
- Division of Community Health Services, Minsitry of Health, Nairobi, Kenya
| | | | - Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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22
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Community health volunteers challenges and preferred income generating activities for sustainability: a qualitative case study of rural Kilifi, Kenya. BMC Health Serv Res 2021; 21:642. [PMID: 34217281 PMCID: PMC8254366 DOI: 10.1186/s12913-021-06693-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 06/23/2021] [Indexed: 12/05/2022] Open
Abstract
Background There is a global emphasis on engaging community health volunteers (CHVs) in low- to middle-income countries (LMICs) to reach to the vast underserved populations that live in rural areas. Retention of CHVs in most countries has however been difficult and turnover in many settings has been reported to be high with profound negative effects on continuity of community health services. In rural Kenya, high attrition among CHVs remains a concern. Understanding challenges faced by CHVs in rural settings and how to reduce attrition rates with sustainable income-generating activities (IGAs) is key to informing the implementation of contextual measures that can minimise high turnover. This paper presents findings on the challenges of volunteerism in community health and the preferred IGAs in rural Kilifi county, Kenya. Methods The study employed qualitative methods. We conducted 8 key informant interviews (KIIs) with a variety of stakeholders and 10 focus group discussions (FGDs) with CHVs. NVIVO software was used to organise and analyse our data thematically. Results Community Health Volunteers work is not remunerated and it conflicts with their economic activities, child care and other community expectations. In addition, lack of supervision, work plans and relevant training is a barrier to delivering CHVs’ work to the communities. There is a need to remunerate CHVs work as well as provide support in the form of basic training and capital on entrepreneurship to implement the identified income generating activities such as farming and events management. Conclusions Strategies to support the livelihoods of CHVs through context relevant income generating activities should be identified and co-developed by the ministry of health and other stakeholders in consultation with the CHVs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06693-w.
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Agarwal S, Abuya T, Kintu R, Mwanga D, Obadha M, Pandya S, Warren CE. Understanding community health worker incentive preferences in Uganda using a discrete choice experiment. J Glob Health 2021; 11:07005. [PMID: 33763219 PMCID: PMC7956012 DOI: 10.7189/jogh.11.07005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving the availability and accessibility to health care. However, CHW programs globally continue to face challenges with poor performance and high levels of CHW attrition. CHW programs are often underfunded and poorly planned, which can lead to loss of motivation by CHWs. The study aims to determine preferences of CHWs for job incentives with the goal of furthering their motivation and success. Methods Relevant incentive attributes were identified through focus group discussions and in-depth interviews with CHWs, non-governmental organization CHWs, CHW supervisors, and policy-level stakeholders. Based on seven attributes (eg, training, workload, stipend) we developed a discrete choice experiment (DCE) that was administered to 399 CHWs across eight districts in Uganda. We used conditional and mixed multinomial logit models to estimate the utility of each job attribute. We calculated the marginal willingness to accept as the trade-off the CHWs were willing to make for a change in salary. Results CHWs preferred higher salaries, though salary was not the most important attribute. There was a preference for reliable transportation, such as a bicycle (β = 1.86, 95% CI = 1.06, 2.67), motorcycle (β = 1.81, 95% CI = 1.27, 2.34) or transport allowance (β = 1.37, 95% CI = 0.65, 2.10) to no transport. Formal identification including identity badges (β = 1.61, 95% CI = 0.72, 2.49), branded uniforms (β = 1.04, 95% CI = 0.45, 1.63) and protective branded gear (β = 0.76, 95% CI = 0.32, 1.21) were preferred compared to no identification. CHWs also preferred more regular refresher trainings, the use of mobile phones as job-aids and a lesser workload. The relative importance estimates suggested that transport was the most important attribute, followed by identification, refresher training, salary, workload, recognition, and availability of tools. CHWs were willing to accept a decrease in salary of USH 31 240 (US$8.5) for identity badges, and a decrease of USH85 300 (US$23) for branded uniforms to no identification. Conclusions This study utilized CHW and policymaker perspectives to identify realistic and pragmatic incentives to improve CHW working conditions, which is instrumental in improving their retention. Non-monetary incentives (eg, identification, transportation) are crucial motivators for CHWs and should be considered as part of the compensation package to facilitate improved performance of CHW programs.
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Affiliation(s)
- Smisha Agarwal
- Department of International Health, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Melvin Obadha
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.,University College, Oxford, UK
| | - Shivani Pandya
- Department of International Health, the Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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24
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Bao M, Huang C. Job preferences of medical and nursing students seeking employment in rural China: a discrete choice experiment. BMC MEDICAL EDUCATION 2021; 21:146. [PMID: 33673842 PMCID: PMC7934374 DOI: 10.1186/s12909-021-02573-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/18/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND China has a shortage of health workers in rural areas, but little research exists on policies that attract qualified medical and nursing students to rural locations. We conducted a discrete choice experiment to determine how specific incentives would be valued by final-year students in a medical university in Guizhou Province, China. METHODS Attributes of potential jobs were developed through the literature review, semi-structured interviews, and a pilot survey. Forty choice sets were developed using a fractional factorial design. A mixed logit model was used to estimate the relative strength of the attributes. Willingness to pay and uptake rates for a defined job were also calculated based on the mixed logit estimates. RESULTS The final sample comprised 787 medical and nursing students. The statistically significant results indicated "Bianzhi" (the number of personnel allocated to each employer by the government) and physical conflicts between doctors and patients were two of the most important non-monetary job characteristics that incentivized both medical and nursing students. Policy simulation suggested that respondents were most sensitive to a salary increase, and the effect of incentive packages was stronger for students with a rural family background. CONCLUSIONS Strategies for patient-doctor relationships, Bianzhi and salary should be considered to attract final-year medical and nursing students to work in rural China. In addition, specific recruitment policy designs tailored for students with different majors and backgrounds should be taken into account.
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Affiliation(s)
- Meiling Bao
- School of Public Health, Sun Yat-sen University, Zhongshan Road #2, Guangzhou, 510080, China
- School of Public Health, Guizhou Medical University, Guiyang, China
| | - Cunrui Huang
- School of Public Health, Sun Yat-sen University, Zhongshan Road #2, Guangzhou, 510080, China.
- School of Public Health, Zhengzhou University, Zhengzhou, China.
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25
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Odendaal W, Lewin S, McKinstry B, Tomlinson M, Jordaan E, Mazinu M, Haig P, Thorson A, Atkins S. Using a mHealth system to recall and refer existing clients and refer community members with health concerns to primary healthcare facilities in South Africa: a feasibility study. Glob Health Action 2020; 13:1717410. [PMID: 32036781 PMCID: PMC7034483 DOI: 10.1080/16549716.2020.1717410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Lay health workers (LHWs) are critical in linking communities and primary healthcare (PHC) facilities. Effective communication between facilities and LHWs is key to this role. We implemented a mobile health (mHealth) system to improve communication and continuity of care for chronically ill clients. The system focused on requests from facility staff to LHWs to follow up clients and LHW referrals of people who needed care at a facility. We implemented the system in two rural and semi-rural sub-districts in South Africa. Objective: To assess the feasibility of the mHealth system in improving continuity of care for clients in PHC in South Africa. Method: We implemented the intervention in 15 PHC facilities. The clerks issued recalls to LHWs using a tablet computer. LHWs used smartphones to receive these requests, communicate with clerks and refer people to a facility. We undertook a mixed-methods evaluation to assess the feasibility of the mHealth system. We analysed recall and referral data using descriptive statistics. We used thematic content analysis to analyse qualitative data from semi-structured interviews with facility staff and a researcher fieldwork journal. Results: Across the sub-districts, 2,204 clients were recalled and 628 (28%) of these recalls were successful. LHWs made 1,085 referrals of which 485 (45%) were successful. The main client group referred and recalled were children under 5 years. Qualitative data showed the impacts of facility conditions and interpersonal relationships on the mHealth system. Conclusion: Using mHealth for recalls and referrals is probably feasible and can improve communication between LHWs and facility staff. However, the low success rates highlight the need to assess facility capacity beforehand and to integrate mHealth with existing health information systems. mHealth may improve communication between LHWs and facility staff, but its success depends on the health system capacity to incorporate these interventions.
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Affiliation(s)
- Willem Odendaal
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
| | - Simon Lewin
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Brian McKinstry
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Mark Tomlinson
- Department of Global Health, Institute for Life Course Health Research, Stellenbosch University, Stellenbosch, South Africa.,School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Esme Jordaan
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,Statistics and Population Studies, University of the Western Cape, Cape Town, South Africa
| | - Mikateko Mazinu
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Pam Haig
- Family South Africa (FAMSA) Karoo, Oudsthoorn, South Africa
| | - Anna Thorson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Salla Atkins
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,New Social Research and Faculty of Social Sciences, Tampere University, Tampere, Finland
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Brunie A, MacCarthy J, Mulligan B, Ribaira Y, Rabemanantsoa A, Rahantanirina L, Parker C, Keyes E. Practical Implications of Policy Guidelines: A GIS Model of the Deployment of Community Health Volunteers in Madagascar. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:466-477. [PMID: 33008858 PMCID: PMC7541125 DOI: 10.9745/ghsp-d-19-00421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/07/2020] [Indexed: 11/15/2022]
Abstract
Geographic information systems can be used to support informed decisions about practical issues related to implementing community health worker (CHW) programs. Demands placed on CHWs regarding expected population and surface area coverage and travel time to facilities need to be carefully considered to ensure they are rational and realistic. Background: With increasing interest in strengthening community health programs nationally comes a need for operationalizing them in a realistic and achievable way. Limited information is available to help program managers establish appropriate parameters for their context. We examined aspects of program implementation related to deployment patterns of community health workers, called agents communautaires or ACs, in 2 districts of Madagascar. Methods: By analyzing program data and publicly available datasets in a geographic information system (GIS), we estimated the population and surface area coverage expected of ACs in 445 fokontany (communities). Additional modeling on travel time demands examined 1-way pedestrian travel time for ACs to receive routine support from their assigned health facilities and from socially marketed supply points under dry season conditions, as well as the impact on travel time based on ACs being reassigned to other facilities or supply points. Results: With the current distribution, ACs in 90% of fokontany have a catchment population of 1,000 or fewer people (2020 estimates) and ACs in 84% of fokontany have a catchment area of 25 km2 or less. We estimated that ACs in 58% of fokontany were located more than 2 hours from their supporting health facility, and the proportion of fokontany with ACs more than 2 hours away from their assigned supply point was 61%. Reassigning ACs to the closest facility or supply point led to modest improvements in those figures (7 and 4 percentage points, respectively). Conclusion: Findings allow visualizing the practical implications of coverage ratios for ACs to assess whether current demands are realistic. The physical access between ACs and the health system warrants significant attention due to challenges in transport and logistics. Analyses are timely to inform the Ministry of Public Health’s strategic thinking in the context of the development of the National Strategic Plan on Strengthening Community Health.
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Affiliation(s)
| | - James MacCarthy
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, NC, USA
| | - Brian Mulligan
- Community Capacity for Health Program, JSI Research & Training Institute, Inc., Antananarivo, Madagascar
| | - Yvette Ribaira
- Community Capacity for Health Program, JSI Research & Training Institute, Inc., Antananarivo, Madagascar
| | - Andry Rabemanantsoa
- Community Capacity for Health Program, JSI Research & Training Institute, Inc., Antananarivo, Madagascar
| | - Louisette Rahantanirina
- Community Capacity for Health Program, JSI Research & Training Institute, Inc., Antananarivo, Madagascar
| | - Caleb Parker
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, NC, USA
| | - Emily Keyes
- Reproductive, Maternal, Newborn and Child Health, FHI 360, Durham, NC, USA
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Kigozi G, Heunis C, Engelbrecht M. Community health worker motivation to perform systematic household contact tuberculosis investigation in a high burden metropolitan district in South Africa. BMC Health Serv Res 2020; 20:882. [PMID: 32943026 PMCID: PMC7499870 DOI: 10.1186/s12913-020-05612-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/31/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND South Africa faces a chronic shortage of professional health workers. Accordingly, community health workers (CHWs) are being employed to mitigate the ongoing health workforce deficiencies. As increased access to quality service delivery hinges upon their motivation, this study explored CHWs' motivation to deliver systematic household contact tuberculosis (TB) investigation (SHCI). METHODS In 2017, a cross-sectional survey was conducted among CHWs in the Mangaung Metropolitan District, Free State Province. Exploratory factor analysis was performed on a 30-item scale to determine the dimensions underlying CHW motivation. Items with factor loadings of 0.4 and above were retained. Descriptive and inferential analyses were used to determine CHW motivation levels. Multiple linear regression analysis was used to investigate the determinants of CHW motivation. RESULTS Out of 235 participants, 89.2% were female. Participants' median age was 39 (inter-quartile range: 33-45) years. CHW motivation was defined by 16 items across three dimensions - intrinsic job satisfaction, burnout and team commitment, together explaining 56.04% of the total variance. The derived scale showed satisfactory internal consistency (Cronbach's alpha: 0.81), with a mean motivation score of 52.26 (standard deviation [sd]: 5.86) out of 64. Statistically significant differences were observed between formal CHWs - those with at least phase 1 standardised accredited training, and informal CHWs - those without such accredited training regarding team commitment scores (17.82 [sd: 2.48] vs. 17.07 [sd: 2.82]; t(233) = 2.157; p = 0.013). CHW age (β = 0.118, p = 0.029), location (β = 1.737, p = 0.041), length of service (β = - 0.495, p < 0.001), attendance of TB SHCI training (β = 1.809, p = 0.036), and TB SHCI competence (β = 0.706, p < 0.001), contributed statistically significantly to CHW motivation. CONCLUSION CHW motivation to perform TB SHCI was both intrinsic and extrinsic. The high overall mean score implies that the CHWs were well-motivated to perform TB SHCI. To ensure sustained improved access to quality TB SHCI service provision, programme managers in the Free State and similar settings could potentially use the tool derived from this study to monitor and inform CHW motivation interventions. Interventions should pay close attention to the CHWs' formalisation, competence and training.
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Affiliation(s)
- Gladys Kigozi
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa.
| | - Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - Michelle Engelbrecht
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
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28
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Schurer JM, Fowler K, Rafferty E, Masimbi O, Muhire J, Rozanski O, Amuguni HJ. Equity for health delivery: Opportunity costs and benefits among Community Health Workers in Rwanda. PLoS One 2020; 15:e0236255. [PMID: 32881867 PMCID: PMC7470334 DOI: 10.1371/journal.pone.0236255] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022] Open
Abstract
Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.
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Affiliation(s)
- Janna M. Schurer
- Center for One Health, University of Global Health Equity, Kigali, Rwanda
- Department of Infectious Disease and Global Health, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, United States of America
| | - Kelly Fowler
- Department of Infectious Disease and Global Health, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, United States of America
| | - Ellen Rafferty
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Ornella Masimbi
- Basic Medical Sciences, University of Global Health Equity, Kigali, Rwanda
| | - Jean Muhire
- Environmental Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Olivia Rozanski
- Department of Infectious Disease and Global Health, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, United States of America
| | - Hellen J. Amuguni
- Center for One Health, University of Global Health Equity, Kigali, Rwanda
- Department of Infectious Disease and Global Health, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, United States of America
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29
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Musoke D, Ndejjo R, Atusingwize E, Ssemugabo C, Ottosson A, Gibson L, Waiswa P. Panacea or pitfall? The introduction of community health extension workers in Uganda. BMJ Glob Health 2020; 5:bmjgh-2020-002445. [PMID: 32816827 PMCID: PMC7430324 DOI: 10.1136/bmjgh-2020-002445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwinah Atusingwize
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Ssemugabo
- 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
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Vallières F, Kok M, Mahmud I, Sarker M, Jeacocke P, Karuga R, Limato L, Kea AZ, Chikaphupha K, Sidat M, Gilmore B, Taegtmeyer M. Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries. HUMAN RESOURCES FOR HEALTH 2020; 18:54. [PMID: 32738907 PMCID: PMC7395979 DOI: 10.1186/s12960-020-00495-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Close-to-community (CTC) health service providers are a cost-effective and important resource in the promotion of and increasing access to health services. However, many CTC provider programmes suffer from high rates of de-motivation and attrition due to inadequate support systems. Recent literature has identified the lack of rigorous approaches towards measuring and monitoring motivation among CTC providers as an important gap. Building on scales used in previous studies, we set out to develop a short, simple-to-administer scale to monitor and measure indicators of CTC provider motivation across CTC programmes implemented in six countries: Ethiopia, Kenya, Malawi, Mozambique, Indonesia, and Bangladesh. METHODS We used focus group discussions (n = 18) and interviews (n = 106) conducted with CTC providers across all six countries, applying thematic analysis techniques to identify key determinants of motivation across these contexts. These themes were then used to carry out a systematic search of the literature, to identify existing scales or questionnaires developed for the measurement of these themes. A composite 24-item scale was then administered to CTC providers (n = 695) across the six countries. Survey responses were subsequently randomly assigned to one of two datasets: the first for scale refinement, using exploratory techniques, and the second for factorial validation. Confirmatory factor analysis was applied to both datasets. RESULTS Results suggest a 12-item, four-factor structure, measuring community commitment, organisational commitment, job satisfaction, and work conscientiousness as common indicators of motivation among CTC providers across the six countries. CONCLUSIONS Consistent with previous studies, findings support the inclusion of job satisfaction, organisational commitment, and work conscientiousness within the CTC Provider Motivation Indicator Scale. In addition, findings further supported the addition of a fourth, community commitment, sub-scale. Practical applications of the revised scale, including how it can be applied to monitor motivation levels within CTC provider programming, are discussed.
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Affiliation(s)
- Frédérique Vallières
- Trinity Centre for Global Health, School of Psychology, Trinity College Dublin, 7-9 Leinster Street South, Dublin 2, Ireland
| | - Maryse Kok
- KIT Royal Tropical Institute, Mauritskade 64, 1092 AD Amsterdam, The Netherlands
| | - Ilias Mahmud
- James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Malabika Sarker
- James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Philippa Jeacocke
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | | | - Licia Limato
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No.69, Jakarta, Indonesia
| | | | | | - Mohsin Sidat
- Department of Community Health, University Eduardo Mondlane, Maputo, Mozambique
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Miriam Taegtmeyer
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
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Muthuri RNDK, Senkubuge F, Hongoro C. Determinants of Motivation among Healthcare Workers in the East African Community between 2009-2019: A Systematic Review. Healthcare (Basel) 2020; 8:E164. [PMID: 32532016 PMCID: PMC7349547 DOI: 10.3390/healthcare8020164] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 12/22/2022] Open
Abstract
Healthcare workers are an essential element in the functionality of the health system. However, the health workforce impact on health systems tends to be overlooked. Countries within the Sub-Saharan region such as the six in the East African Community (EAC) have weak and sub-optimally functioning health systems. As countries globally aim to attain Universal Health Coverage and the Sustainable Development Goal 3, it is crucial that the significant role of the health workforce in this achievement is recognized. In this systematic review, we aimed to synthesise the determinants of motivation as reported by healthcare workers in the EAC between 2009 and 2019. A systematic search was performed using four databases, namely Cochrane library, EBSCOhost, ProQuest and PubMed. The eligible articles were selected and reviewed based on the authors' selection criteria. A total of 30 studies were eligible for review. All six countries that are part of the EAC were represented in this systematic review. Determinants as reported by healthcare workers in six countries were synthesised. Individual-level-, organizational/structural- and societal-level determinants were reported, thus revealing the roles of the healthcare worker, health facilities and the government in terms of health systems and the community or society at large in promoting healthcare workers' motivation. Monetary and non-monetary determinants of healthcare workers' motivation reported are crucial for informing healthcare worker motivation policy and health workforce strengthening in East Africa.
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Affiliation(s)
- Rose Nabi Deborah Karimi Muthuri
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa; (F.S.); (C.H.)
| | - Flavia Senkubuge
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa; (F.S.); (C.H.)
| | - Charles Hongoro
- School of Health Systems and Public Health (SHSPH), Faculty of Health Sciences, University of Pretoria, Pretoria 0028, Gauteng Province, South Africa; (F.S.); (C.H.)
- Developmental, Capable and Ethical State Division, Human Sciences Research Council (HSRC), Pretoria 0001, Gauteng Province, South Africa
- Faculty of Science, Tshwane University of Technology, Pretoria 0183, Gauteng Province, South Africa
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Majee W, Schopp L, Johnson L, Anakwe A, Rhoda A, Frantz J. Emerging from the Shadows: Intrinsic and Extrinsic Factors Facing Community Health Workers in Western Cape, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E3199. [PMID: 32375417 PMCID: PMC7246890 DOI: 10.3390/ijerph17093199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/08/2020] [Accepted: 04/20/2020] [Indexed: 11/24/2022]
Abstract
Community health workers (CHWs) have been identified as a key component of the health workforce in South Africa. However, the efficacy of CHW programs continues to be limited by a poor understanding of facilitators and barriers to CHW engagement. This study explores intrinsic and extrinsic factors that CHWs face. We conducted in-depth interviews with 20 CHWs in order to understand the challenges they may face as they implement their duties linked to the primary health care strategy in the Western Cape, South Africa. All interviews were audiotaped, transcribed verbatim, coded and analyzed using NVivo 12. Drawing on narratives of CHWs, we illustrate the complex issues surrounding CHW outreach in poor rural communities. The CHWs identified five key areas of challenges with respect to personal health, gender issues, poor community understanding of CHWs roles, environmental challenges and lack of patient adherence. These all hinder the ability of CHWs to meet their personal and familial needs, as well as those of the community members they support. There is a need to address the intrinsic needs of CHWs in order to ensure their emotional and physical well-being, as well as a need to create an awareness of the roles of CHWs.
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Affiliation(s)
- Wilson Majee
- Department of Health Sciences and Public Health, University of Missouri, Columbia, MO 65211, USA
- Department of Occupational Therapy, Faculty of Community and Health Science, University of the Western Cape, Western Cape, Bellville 7535, South Africa
| | - Laura Schopp
- Department of Health Psychology, University of Missouri, Columbia, MO 65211, USA;
| | - Levona Johnson
- Department of Physiotherapy, Faculty of Community and Health Science, University of the Western Cape, Western Cape, Bellville 7535, South Africa; (L.J.); (A.R.); (J.F.)
| | - Adaobi Anakwe
- Master of Public Health Program, University of Missouri, Columbia, MO 65211, USA;
| | - Anthea Rhoda
- Department of Physiotherapy, Faculty of Community and Health Science, University of the Western Cape, Western Cape, Bellville 7535, South Africa; (L.J.); (A.R.); (J.F.)
| | - Jose Frantz
- Department of Physiotherapy, Faculty of Community and Health Science, University of the Western Cape, Western Cape, Bellville 7535, South Africa; (L.J.); (A.R.); (J.F.)
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The relative importance of material and non-material incentives for community health workers: Evidence from a discrete choice experiment in Western Kenya. Soc Sci Med 2020; 246:112726. [DOI: 10.1016/j.socscimed.2019.112726] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 11/19/2022]
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Ndejjo R, Musinguzi G, Nuwaha F, Wanyenze RK, Bastiaens H. Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study. BMC Public Health 2020; 20:75. [PMID: 31948423 PMCID: PMC6966788 DOI: 10.1186/s12889-020-8188-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are on the rise in many low-and middle-income countries where 80% of related deaths are registered. Community CVD prevention programmes utilizing self-care approaches have shown promise in contributing to population level reduction of risk factors. However, the acceptability of these programmes, which affects their uptake and effectiveness, is unknown including in the sub-Saharan Africa context. This study used the Theoretical Framework of Acceptability to explore the prospective acceptability of a community CVD prevention programme in Mukono and Buikwe districts in Uganda. METHODS This qualitative descriptive study was conducted in March 2019 among community health workers (CHWs), who would implement the intervention and community members, the intervention recipients, using eight focus group discussions. All discussions were audio-recorded, transcribed verbatim and analysed thematically guided by the theoretical framework. RESULTS CHWs and community members reported high eagerness to participate in the programme. Whereas CHWs had implemented similar community programmes and cited health promotion as their role, community members looked forward to health services being brought nearer to them. Although the intervention was preventive in nature, CHWs and community members expressed high interest in treatments for risk factors and were skeptical about the health system capacity to deliver them. CHWs anticipated barriers in mobilising communities who they said sometimes may not be cooperative while community members were concerned about failing to access treatment and support services after screening for risk factors. The major cost to CHWs and community members for engaging in the intervention was time that they would have dedicated to income generating activities and social events though CHWs also had the extra burden of being exemplary. CHWs were confident in their ability to deliver the intervention as prescribed if well trained, supported and supervised, and community members felt that if provided sufficient information and supported by CHWs, they could change their behaviours. CONCLUSIONS The community CVD prevention programme was highly acceptable among CHWs and community members in Mukono and Buikwe districts of Uganda amidst a few burdens and opportunity costs. Suggestions made by study participants to improve programme effectiveness informed programme design and implementation for impact.
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Affiliation(s)
- Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Primary and Interdisciplinary care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Geofrey Musinguzi
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Primary and Interdisciplinary care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Fred Nuwaha
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Hilde Bastiaens
- Department of Primary and Interdisciplinary care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Kok M, Abdella D, Mwangi R, Ntinginya M, Rood E, Gassner J, Church K, Wheatley N. Getting more than "claps": incentive preferences of voluntary community-based mobilizers in Tanzania. HUMAN RESOURCES FOR HEALTH 2019; 17:101. [PMID: 31847909 PMCID: PMC6918602 DOI: 10.1186/s12960-019-0438-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/11/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Marie Stopes Tanzania works with a voluntary cadre of 66 community-based mobilizers (CBMs), who are tasked with raising awareness, generating demand and providing referral to potential clients for family planning, comprehensive post-abortion care and cervical cancer screening. CBMs extend the reach of urban clinics to peri-urban communities, enhancing access to sexual and reproductive health services. In an effort to optimize performance of CBMs, a study was conducted to explore the drivers of CBM motivation and inform the design of an incentive scheme. METHODS Three focus group discussions with 17 CBMs and 11 interviews with CBM supervisors and managers were conducted in three clinics and the head office. After thematic analysis of transcripts, findings on motivational factors were discussed in a reflection workshop and informed the development of a discrete choice experiment (DCE) involving 61 CBMs as respondents. The DCE included eight choice questions on two incentive schemes, each consisting of five attributes related to remuneration, training, supervision, benefits and identification. For each attribute, different incentive options were presented, based on the outcomes of the qualitative assessment. The DCE results were analysed using conditional logistic regression. RESULTS A variety of factors motivated CBMs. Most CBMs were motivated to conduct their work because of an intrinsic desire to serve their community. The most mentioned extrinsic motivational factors were recognition from the community and supervisors, monthly allowance, availability of supporting materials and identification, trainings, supervision and feedback on performance. Recommendations for improvement were translated into the DCE. Incentive attributes that were found to be significant in DCE analysis (p < 0.05), in preference order, were carrying an ID card, bi-monthly training, supervision conducted via both monthly meetings at clinics and visits from the head office, and a monthly flat rate remuneration (over pay for performance). CONCLUSION Despite the recognition that being a CBM is voluntary, incentives, especially those of non-financial nature, are important motivators. Incentive schemes should include basic compensation with a mix of other incentives to facilitate CBMs' work and enhance their motivation. Programme designs need to take into account the voices of community-based workers, to optimize their performance and service delivery to communities they serve.
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Affiliation(s)
- Maryse Kok
- KIT Royal Tropical Institute, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Dinu Abdella
- KIT Royal Tropical Institute, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Rose Mwangi
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMC), P.O. Box 2240, Moshi, Tanzania
| | - Mengi Ntinginya
- Marie Stopes Tanzania, P.O. Box 7072, Das es Salaam, Tanzania
| | - Ente Rood
- KIT Royal Tropical Institute, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Jennifer Gassner
- Marie Stopes International, 1 Conway Street Fitzroy Square, London, W1T 6LP United Kingdom
| | - Kathryn Church
- Marie Stopes International, 1 Conway Street Fitzroy Square, London, W1T 6LP United Kingdom
| | - Nkemdiri Wheatley
- Marie Stopes International, 1 Conway Street Fitzroy Square, London, W1T 6LP United Kingdom
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Agarwal S, Anaba U, Abuya T, Kintu R, Casseus A, Hossain S, Obadha M, Warren CE. Understanding incentive preferences of community health workers using discrete choice experiments: a multicountry protocol for Kenya, Uganda, Bangladesh and Haiti. BMJ Open 2019; 9:e033601. [PMID: 31831550 PMCID: PMC6924748 DOI: 10.1136/bmjopen-2019-033601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION There is a renewed global interest in improving community health worker (CHW) programmes. For CHW programmes to be effective, key intervention design factors which contribute to the performance of CHWs need to be identified. The recent WHO guidelines recommends the combination of financial and non-financial incentives to improve CHW performance. However, evidence gaps remain as to what package of incentives will improve their performance in different country contexts. This study aims to evaluate CHW incentive preferences to improve performance and retention which will strengthen CHW programmes and help governments leverage limited resources appropriately. METHODS AND ANALYSIS A discrete choice experiment (DCE) will be conducted with CHWs in Bangladesh, Haiti, Kenya and Uganda with different levels of maturity of CHWs programmes. This will be carried out in two phases. Phase 1 will involve preliminary qualitative research including focus group discussions (FGDs) and key informant interviews to develop the DCE design which will include attributes relevant to the CHW country settings. Phase 2 will involve a DCE survey with CHWs, presenting them with a series of job choices with varying attribute levels. An orthogonal design will be used to generate the choice sets for the surveys. The surveys will be administered in locally-appropriate languages to at least 150 CHWs from each of the cadres in each country. Conditional and mixed multinomial logit (MMNL) models will be used for the estimation of stated preferences. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Population Council's Institutional Review Board in New York, and appropriate ethics review boards in Kenya, Uganda, Bangladesh and Haiti. The results of the study will be disseminated through in-country dissemination workshops, meetings with country-level stakeholders and policy working groups, print media, online blogs and peer-reviewed journals.
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Affiliation(s)
- Smisha Agarwal
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Timothy Abuya
- Reproductive Health Program, Population Council, Nairobi, Kenya
| | | | | | | | - Melvin Obadha
- Health Economics Research Unit, KEMRI, Nairobi, Kenya
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Musoke D, Ndejjo R, Atusingwize E, Mukama T, Ssemugabo C, Gibson L. Performance of community health workers and associated factors in a rural community in Wakiso district, Uganda. Afr Health Sci 2019; 19:2784-2797. [PMID: 32127852 PMCID: PMC7040253 DOI: 10.4314/ahs.v19i3.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Community health workers (CHWs) continue to play a crucial role in supporting health service delivery globally. Several CHW programmes around the world face vast challenges which affect their performance. Objectives This study assessed the performance of CHWs and associated factors in a rural community in Wakiso district, Uganda. Methods This was a cross-sectional study that employed a structured questionnaire to collect quantitative data from 201 CHWs in Wakiso district. The main study variable was CHW performance based on various roles carried out by CHWs. Multivariable logistic regression in STATA was used to establish the predictors of CHW performance. Results Only 40 (19.9%) of the CHWs had a high performance which was associated with having attended additional / refresher trainings [AOR=12.79 (95% CI: 1.02–159.26)], and having attained secondary level education and above [AOR=3.93 (95% CI: 1.17–13.24)]. CHWs who were married [AOR=0.29 (95% CI: 0.09–0.94)] were less likely to perform highly. Among CHWs who had received essential medicines for treatment of childhood illnesses, the majority 90.3% (112/124) had experienced stock-outs in the 6 months preceding the study. Despite the majority of CHWs, 198 (98.5%), stating that being motivated was very important in their work, only 91 (45%) said that they were motivated. Conclusion Additional / refresher trainings are necessary to enhance performance of CHWs. In addition, level of education should be considered while selecting CHWs. The health system challenges of low motivation of CHWs as well as stock-out of medicines need to be addressed to support their work.
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Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwinah Atusingwize
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Trasias Mukama
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Charles Ssemugabo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Linda Gibson
- School of Social Sciences, Nottingham Trent University, Nottingham, UK
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Ormel H, Kok M, Kane S, Ahmed R, Chikaphupha K, Rashid SF, Gemechu D, Otiso L, Sidat M, Theobald S, Taegtmeyer M, de Koning K. Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation. HUMAN RESOURCES FOR HEALTH 2019; 17:59. [PMID: 31324192 PMCID: PMC6642499 DOI: 10.1186/s12960-019-0387-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/20/2019] [Indexed: 05/28/2023]
Abstract
BACKGROUND The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. METHODS We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. RESULTS We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. CONCLUSIONS Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.
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Affiliation(s)
- Hermen Ormel
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Maryse Kok
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Sumit Kane
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
| | - Rukhsana Ahmed
- Eijkman Institute for Molecular Biology, Jalan Diponegoro 69, Jakarta, 10430 Indonesia
| | - Kingsley Chikaphupha
- Research for Equity and Community Health (REACH) Trust, P.O. Box 1597, Lilongwe, Malawi
| | - Sabina Faiz Rashid
- BRAC James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka Bangladesh
| | | | - Lilian Otiso
- LVCT Health, Research and Strategic Information Department, P.O. Box 19835-00202, Nairobi, Kenya
| | - Mohsin Sidat
- Department of Community Health, University Eduardo Mondlane, P.O. Box 257, Maputo, Mozambique
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - Korrie de Koning
- Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA Amsterdam, The Netherlands
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Okelloh D, Achola M, Opole J, Ogwang C, Agaya J, Sifuna P, Mchembere W, Cowden J, Heilig M, Borgdorff MW, Yuen CM, Cain KP. Lessons learned from community-based tuberculosis case-finding in western Kenya. Public Health Action 2019; 9:53-57. [PMID: 31417853 PMCID: PMC6645444 DOI: 10.5588/pha.18.0085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/15/2019] [Indexed: 11/10/2022] Open
Abstract
SETTING Although Kenya has a high burden of tuberculosis (TB), only 46% of cases were diagnosed in 2016. OBJECTIVE To identify strategies for increasing attendance at community-based mobile screening units. DESIGN We analysed operational data from a cluster-randomised trial, which included community-based mobile screening implemented during February 2015-April 2016. Community health volunteers (CHVs) recruited individuals with symptoms from the community, who were offered testing for human immunodeficiency virus (HIV) and sputum collection for Xpert® MTB/RIF testing. We compared attendance across different mobile unit sites using Wilcoxon rank-sum test. RESULTS A total of 1424 adults with symptoms were screened at 25 mobile unit sites. The median total attendance among sites was 54 (range 6-134, interquartile range [IQR] 24-84). The median yields of TB diagnoses and new HIV diagnoses were respectively 2.4% (range 0.0-16.7, IQR 0.0-5.3) and 2.5% (range 0.0-33.3, IQR 1.2-4.2). Attendance at urban sites was variable; attendance at rural sites where CHVs were paid a daily minimum wage was significantly higher than at rural sites where CHVs were paid a nominal monthly stipend (P < 0.001). CONCLUSION Mobile units were most effective and efficient when implemented as a single event with community health workers who are paid a daily wage.
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Affiliation(s)
- D Okelloh
- Kenya Medical Research Institute, Kisumu, Kenya
| | - M Achola
- Kenya Medical Research Institute, US Army Medical Research Directorate-Kenya, Kisumu, Kenya
| | - J Opole
- Kenya Medical Research Institute, Kisumu, Kenya
| | - C Ogwang
- Kenya Medical Research Institute, Kisumu, Kenya
| | - J Agaya
- Kenya Medical Research Institute, Kisumu, Kenya
| | - P Sifuna
- US Army Medical Research Directorate-Kenya, Kisumu, Kenya
| | - W Mchembere
- Kenya Medical Research Institute, Kisumu, Kenya
| | - J Cowden
- US Army Medical Research Directorate-Kenya, Kisumu, Kenya
| | - M Heilig
- US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - M W Borgdorff
- US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - C M Yuen
- Harvard Medical School, Boston, Massachusetts, USA
| | - K P Cain
- US Centers for Disease Control and Prevention, Kisumu, Kenya
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Abbo C, Mwaka AD, Opar BT, Idro R. Qualitative evaluation of the outcomes of care and treatment for children and adolescents with nodding syndrome and other epilepsies in Uganda. Infect Dis Poverty 2019; 8:30. [PMID: 31036087 PMCID: PMC6489326 DOI: 10.1186/s40249-019-0540-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background In 2012, the Ugandan Government declared an epidemic of Nodding Syndrome (NS) in the Northern districts of Gulu, Kitgum, Lamwo and Pader. Treatment guidelines were developed and NS treatment centres were established to provide symptomatic control and rehabilitation. However, a wide gap remained between the pre-defined care standards and the quality of routine care provided to those affected. This study is to qualitatively assess adherence to accepted clinical care standards for NS; identify gaps in the care of affected children and offer Clinical Support Supervision (CSS) to Primary Health Care (PHC) staff at the treatment centres; and identify psychosocial challenges faced by affected children and their caregivers. Methods This case study was carried out in the districts of Gulu, Kitgum, Lamwo and Pader in Uganda from September to December in 2015. Employing the 5-stage approach of Clinical Audit, data were collected through direct observations and interviews with PHC providers working in public and private-not-for-profit health facilities, as well as with caregivers and political leaders. The qualitative data was analysed using Seidel model of data processing. Results Clinical Audit and CSS revealed poor adherence to treatment guidelines. Many affected children had sub-optimal NS management resulting in poor seizure control and complications including severe burns. Root causes of these outcomes were frequent antiepileptic drugs stock outs, migration of health workers from their work stations and psychosocial issues. There was hardly any specialized multidisciplinary team (MDT) to provide for the complex rehabilitation needs of the patients and a task shifting model with inadequate support supervision was employed, leading to loss of skills learnt. Reported psychosocial and psychosexual issues associated with NS included early pregnancies, public display of sexual behaviours and child abuse. Conclusions Despite involvement of relevant MDT members in the development of multidisciplinary NS guidelines, multidisciplinary care was not implemented in practice. There is urgent need to review the NS clinical guidelines. Quarterly CSS and consistent anticonvulsant medication are needed at health facilities in affected communities. Implementation of the existing policies and programs to deal with the psychosocial and psychosexual issues that affect children with NS and other chronic conditions is needed. Electronic supplementary material The online version of this article (10.1186/s40249-019-0540-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catherine Abbo
- Department of Psychiatry, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Amos Deogratius Mwaka
- Department of Medicine, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Richard Idro
- Department of Paediatrics, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
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Brunie A, Mercer S, Chen M, Andrianantoandro T. Expanding Understanding of Community Health Worker Programs: A Cross-Sectional Survey on the Work, Satisfaction, and Livelihoods of CHWs in Madagascar. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 55:46958018798493. [PMID: 30215263 PMCID: PMC6144492 DOI: 10.1177/0046958018798493] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With health worker shortages in rural areas, community health workers (CHWs) are instrumental to the sustainability of primary health care and to the ability to meet health needs. Identifying appropriate operational models and incentive structures is an important element of long-term success. This article reports on CHWs’ work demands and affective response to their volunteer work within the broader context of their livelihoods in Madagascar. A cross-sectional survey of 874 CHWs, called Agents de Santé Communautaire (ACs), from 14 districts across 5 regions was conducted in June 2015. Only 44% of ACs had cash savings. Subsistence farming was the main livelihood strategy; ninety-two percent of ACs were food insecure and 89% had experienced a shock in the past year. Overall, 77% of ACs financed commodity resupply through sales of health products and 18% from their personal savings; stock-outs at point of supply and financial and time constraints were the main reported challenges in getting health products. The average satisfaction score with AC work was 3 out of 4. This assessment from Madagascar helps unveil a more comprehensive view of the reality of CHWs’ lives. Managers need to take into account the potential implications of the demands of CHW work on already precarious livelihoods.
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Introducing post-discharge malaria chemoprevention (PMC) for management of severe anemia in Malawian children: a qualitative study of community health workers' perceptions and motivation. BMC Health Serv Res 2018; 18:984. [PMID: 30567567 PMCID: PMC6299958 DOI: 10.1186/s12913-018-3791-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/04/2018] [Indexed: 11/17/2022] Open
Abstract
Background Severe malarial anaemia is one of the leading causes of paediatric hospital admissions in Malawi. Post-discharge malaria chemoprevention (PMC) is the intermittent administration of full treatment courses of antimalarial to children recovering from severe anaemia and findings suggest that this intervention significantly reduces readmissions and deaths in these children. Community delivery of health interventions utilizing community health workers (CHWs) has been successful in some programmes and not very positive in others. In Malawi, there is an on-going cluster randomised trial that aims to find the optimum strategy for delivery of dihydroartemesinin-piperaquine (DHP) for PMC in children with severe anaemia. Our qualitative study aimed to explore the feasibility of utilizing CHWs also known as health surveillance assistants (HSAs) to remind caregivers to administer PMC medication in the existing Malawian health system. Methods Between December 2016 and March 2018, 20 individual in-depth-interviews (IDIs) and 2 focus group discussions (FGDs) were conducted with 39 HSAs who had the responsibility of conducting home visits to remind caregivers of children who were prescribed PMC medication in the trial. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were uploaded to NVIVO 11 and analysed using the thematic framework analysis method. Results Although intrinsic motivation was reportedly high, adherence to the required number of home visits was very poor with only 10 HSAs reporting full adherence. Positive factors for adherence were the knowledge and perception of the effectiveness of PMC and the recognition from the community as well as health system. Poor training, lack of supervision, high workload, as well as technical and structural difficulties; were reported barriers to adherence by the HSAs. Conclusions Post-discharge malaria chemoprevention with DHP is perceived as a positive approach to manage children recovering from severe anaemia by HSAs in Malawi. However, adherence to home visit reminders was very poor and the involvement of HSAs in a scale up of this intervention may pose a challenge in the existing Malawian health system. Trial registration ClinicalTrials.gov identifier NCT02721420. The trial was registered on 26 March 2016. Electronic supplementary material The online version of this article (10.1186/s12913-018-3791-5) contains supplementary material, which is available to authorized users.
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Jigssa HA, Desta BF, Tilahun HA, McCutcheon J, Berman P. Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions. HUMAN RESOURCES FOR HEALTH 2018; 16:57. [PMID: 30409189 PMCID: PMC6225677 DOI: 10.1186/s12960-018-0319-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 09/28/2018] [Indexed: 05/30/2023]
Abstract
BACKGROUND The use of community health workers (CHWs) has been considered as one of the strategies to address the growing shortage of health workers, predominantly in low-income countries. They are playing a pivotal role in lessening health disparities through improving health outcomes for underserved populations. Yet, little is known about what factors motivate and drive them to continue working as CHWs. In this study, we aimed to examine factors contributing to the motivation of volunteer CHWs (vCHWs) in Ethiopia currently known as one-to-five network leaders (1to5NLs) and explore variations between attributes of social and work-related determinants. METHOD We conducted a cross-sectional study in four selected woredas (the second lowest administrative structure in Ethiopia, and similar to a district) of Oromia and Tigray regions and interviewed 786 1to5NLs. The effects of each motivational factor were explored using percentage of respondents who agreed and strongly agreed to each of them and Mann-Whitney U test. RESULTS Individual, community, and health system factors contributed to the motivation of 1to5NLs in this study. Intrinsic desire to have a good status in the community as a result of their volunteer service (81.86%) followed by a commitment to serve the community (81.61%) and to gain satisfaction by accomplishing something worthwhile to the community (81.61%) were some of the factors motivating 1to5NLs in our study. Despite these motivational items, factors such as lack of career development (51.47%), unclear health development army guideline (59.26%), limited supervision and support (62.32%), and lack of recognition and appreciation of accomplishments (63.22%) were the factors negatively affecting motivation of 1to5NLs. Lack of career development, limited supervision and support, and lack of recognition and appreciation of accomplishments were significantly varied between attributes of educational level, marital status, service year as 1to5NLs, and previous volunteer engagement (at P < 0.05). CONCLUSION Findings of our study indicated that non-financial incentives such as the creation of career development models is the key to motivating and retaining CHWs where they are not receiving stipends. Sustainability of CHW program should consider exploring enhanced innovations to strengthen supportive supervision, development of better mechanisms to publicize the role of CHWs, and improvement of recognition and appreciation schemes for CHWs' efforts and accomplishments.
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Affiliation(s)
- Habtamu Abdissa Jigssa
- International Division, John Snow Research and Training Institute, Inc., Addis Ababa, Ethiopia
- John Snow Research and Training Institute, Inc., Fenot Project, Bole Sub City, Woreda 03/05, House No. 2347, PO Box 1988, 1250 Addis Ababa, Ethiopia
| | - Binyam Fekadu Desta
- International Division, John Snow Research and Training Institute, Inc., Addis Ababa, Ethiopia
| | - Hibret Alemu Tilahun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA United States of America
| | - Jen McCutcheon
- International Division, John Snow Research and Training Institute, Inc., Addis Ababa, Ethiopia
| | - Peter Berman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA United States of America
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Ngugi AK, Nyaga LW, Lakhani A, Agoi F, Hanselman M, Lugogo G, Mehta KM. Prevalence, incidence and predictors of volunteer community health worker attrition in Kwale County, Kenya. BMJ Glob Health 2018; 3:e000750. [PMID: 30105093 PMCID: PMC6074629 DOI: 10.1136/bmjgh-2018-000750] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/12/2018] [Accepted: 06/16/2018] [Indexed: 11/05/2022] Open
Abstract
Introduction In underserved populations, the contribution of community health workers (CHWs) is vital to the healthcare systems. Attrition of these workers causes critical breakdowns in the delivery of essential services to these populations. Literature on reasons for attrition is limited, although some have been identified in studies on sustainability of CHW programmes. These factors are, however, likely to be influenced by context. We measured CHW attrition and its predictors in a rural area in Kenya. Methods We conducted a nested case–control study and focus group discussions among CHWs involved in a maternal and child health project. A training register of 1005 CHWs was used to sample and follow CHWs for attrition. Incidence of CHW attrition was calculated using a Poisson model. Separately, we used logistic regression to determine predictors of CHW attrition. Results Of the 1005 CHWs, 498 (49.6%) had left the project by the time of the study. The incidence of attrition was 46.8/1000 person-years (95% CI 38.7 to 56.5). In the case–control study, lack of interest in peer organisation membership (OR 5.3; 95% CI 1.3 to 20.6) was associated with attrition. Absence of refresher training (OR 4.0; 95% CI 2.2 to 7.1) and receiving no feedback from supervisors (OR 2.0; 95% CI 1.0 to 3.9) were also associated with attrition. Discordance in expectations and perceived heavy workload were also identified as key reasons for attrition in the qualitative study. Conclusion This study estimates high prevalence and incidence of CHW attrition in Kwale County, Kenya. Ongoing training, feedback and peer support are also important in enhancing retention of CHWs. Additionally, expectations regarding the roles and benefits of involvement in CHW work should be communicated clearly, and workload should be kept reasonable or negotiated with the CHWs.
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Affiliation(s)
- Anthony K Ngugi
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Lucy W Nyaga
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Amyn Lakhani
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Felix Agoi
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - Margrette Hanselman
- Centre for Population Health Sciences, Faculty of Health Sciences, Aga Khan University (EA), Nairobi, Kenya
| | - George Lugogo
- Lungalunga Sub-county Public Health Office, Lungalunga Sub-county, Kwale County, Kenya
| | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O’Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018. [DOI: 10.7189/jogh.06.0207028.010401] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O'Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018; 8:010401. [PMID: 29497500 PMCID: PMC5823030 DOI: 10.7189/jogh.08.010401] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background The continued success of community case management (CCM) programs in low-resource settings depends on the ability of these programs to retain the community health workers (CHWs), many of whom are volunteers, and maintain their high-quality performance. This study aims to identify factors related to the motivation and satisfaction of CHWs working in a malaria CCM program in two sub-counties in Western Kenya. Methods We interviewed 70 CHWs who were trained to administer malaria rapid diagnostic tests as part of a broader study evaluating a malaria CCM program. We identified factors related to CHWs' motivation and their satisfaction with participation in the program, as well as the feasibility of program scale-up. We used principal components analysis to develop an overall CHW satisfaction score and assessed associations between this score and individual CHW characteristics as well as their experiences in the program. Results The majority of CHWs reported that they were motivated to perform their role in this malaria CCM program by a personal desire to help their community (69%). The most common challenge CHWs reported was a lack of community understanding about malaria diagnostic testing and CHWs' role in the program (39%). Most CHWs (89%) reported that their involvement in the diagnostic testing intervention had either a neutral or a net positive effect on their other CHW activities, including improving skills applicable to other tasks. CHWs who said they strongly agreed with the statement that their work with the malaria program was appreciated by the community had a 0.76 standard deviation (SD) increase in their overall satisfaction score (95% confidence interval CI = 0.10-1.24, P = 0.03). Almost all CHWs (99%) strongly agreed that they wanted to continue their role in the malaria program. Conclusions Overall, CHWs reported high satisfaction with their role in community-based malaria diagnosis, though they faced challenges primarily related to community understanding and appreciation of the services they provided. CHWs' perceptions that the malaria program generally did not interfere with their other activities is encouraging for the sustainability and scale-up of similar CHW programs.
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Affiliation(s)
| | - Adriane Lesser
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Diana Menya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joy N Baumgartner
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Indrani Saran
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Wendy Prudhomme-O'Meara
- Duke University, Durham, North Carolina, USA.,Duke University, Duke Global Health Institute, Durham, North Carolina, USA.,Moi University, School of Public Health, Eldoret, Kenya
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Brown L, Lee TH, De Allegri M, Rao K, Bridges JF. Applying stated-preference methods to improve health systems in sub-Saharan Africa: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2017; 17:441-458. [PMID: 28875767 DOI: 10.1080/14737167.2017.1375854] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Sub-Saharan African health systems must balance shifting disease burdens with desires for robust institutions. Stated-preference methods have been applied extensively to elicit health care workers' preferences and priorities for rural practice. This systematic review characterizes the range of their applications to African health systems problems. Areas covered: A PRISMA protocol was submitted to PROSPERO. Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-off. Quality was assessed using the PREFS checklist. Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based: discrete-choice experiments (n = 46), ranking/allocation techniques (n = 21), conjoint analyses (n = 7), and best-worst scaling (n = 3). Trade-offs fell into six 'building blocks': service features (n = 27), workforce incentives (n = 17), product features (n = 14), system priorities (n = 14), insurance features (n = 4), and research priorities (n = 1). Five countries dominated: South Africa (n = 11), Ghana (n = 9), Malawi (n = 9), Uganda (n = 9), and Tanzania (n = 8). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Expert commentary: Stated-preference methods have been applied to many health systems contexts throughout sub-Saharan Africa. Studies examined established strategic areas, especially primary health care for women, prevention and treatment of infectious diseases, and workforce development. Studies have neglected the emerging areas of non-communicable diseases.
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Affiliation(s)
- Lauren Brown
- a Department of International Health , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Ting-Hsuan Lee
- b Department of International Health/Department of Health Policy and Management , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Manuela De Allegri
- c Institute of Public Health, Faculty of Medicine , Heidelberg University , Heidelberg , Germany
| | - Krishna Rao
- a Department of International Health , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - John Fp Bridges
- b Department of International Health/Department of Health Policy and Management , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Burkot C, Naidi L, Seehofer L, Miles K. Perceptions of incentives offered in a community-based malaria diagnosis and treatment program in the Highlands of Papua New Guinea. Soc Sci Med 2017; 190:149-156. [PMID: 28863338 DOI: 10.1016/j.socscimed.2017.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/20/2017] [Accepted: 08/21/2017] [Indexed: 10/19/2022]
Abstract
What motivates community-based health workers to provide care in rural and remote areas, often on a voluntary or casual basis, is a key question for program managers and public health officials. This paper examines how a range of incentives offered as part of the Marasin Stoa Kipa program, a community-based malaria diagnosis and treatment program that has been implemented since 2007 within a major oil and gas development area in Papua New Guinea, are perceived and critiqued by community-based health workers. Nineteen interviews and seven focus group discussions with the workers who deliver services and members of the communities served by the program, conducted between November 4 and 25, 2015, reveal a pattern of mixed motivations and changes in motivation over time. This can be attributed partly to the unique social and economic circumstances in which the program is operating. Changes in the burden of disease as well as in global and national health services policy with implications for local level program operations also had an impact, as did the nature of relationships between program managers, community-based health workers, and program beneficiaries. Overall, the findings suggest that while financial and in-kind incentives can be a useful tool to motivate voluntary or minimally-compensated community-based health workers, they must be carefully structured to align with local social, economic, and epidemiological realities over the long-term.
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Affiliation(s)
- Camilla Burkot
- Development Policy Centre, Crawford School of Public Policy, ANU College of Asia and the Pacific, The Australian National University, Building 132, Lennox Crossing, Acton, Canberra ACT 2601, Australia.
| | - Laura Naidi
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, Eastern Highlands Province 441, Papua New Guinea
| | - Liesel Seehofer
- Oil Search Foundation, PO Box 842, Port Moresby, Papua New Guinea
| | - Kevin Miles
- Oil Search Foundation, PO Box 842, Port Moresby, Papua New Guinea
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Mays DC, O’Neil EJ, Mworozi EA, Lough BJ, Tabb ZJ, Whitlock AE, Mutimba EM, Talib ZM. Supporting and retaining Village Health Teams: an assessment of a community health worker program in two Ugandan districts. Int J Equity Health 2017; 16:129. [PMID: 28728553 PMCID: PMC5520299 DOI: 10.1186/s12939-017-0619-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 07/03/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Uganda's national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, we examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. We report on findings from a standardized survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda. METHODS A mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged. RESULTS VHTs desire additional support primarily in the forms of money (e.g. transportation allowance) and material supplies (e.g. rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health center staff and greater ease in home visiting. CONCLUSIONS Supporting and retaining Uganda's VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.
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Affiliation(s)
- Daniel C. Mays
- George Washington University School of Medicine & Health Sciences, 2300 Eye St. NW, Washington D.C., 20037 USA
| | | | - Edison A. Mworozi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Benjamin J. Lough
- University of Illinois at Urbana-Champaign, School of Social Work, 1010 W. Nevada Street, Urbana, IL 61801 USA
| | - Zachary J. Tabb
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903 USA
| | - Ashlyn E. Whitlock
- George Washington University School of Medicine & Health Sciences, 2300 Eye St. NW, Washington D.C., 20037 USA
| | | | - Zohray M. Talib
- George Washington University School of Medicine & Health Sciences, 2300 Eye St. NW, Washington D.C., 20037 USA
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Gupta P, Iyengar SD, Ganatra B, Johnston HB, Iyengar K. Can community health workers play a greater role in increasing access to medical abortion services? A qualitative study. BMC WOMENS HEALTH 2017; 17:37. [PMID: 28545584 PMCID: PMC5445398 DOI: 10.1186/s12905-017-0391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 05/11/2017] [Indexed: 11/23/2022]
Abstract
Background Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals. Methods In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed. Results Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation. Conclusions Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women’s concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting. Trial registration Not applicable.
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Affiliation(s)
- Pallavi Gupta
- Action Research & Training for Health (ARTH), Satyam, Ramgiri, Badgaon, Udaipur, Rajasthan, 313011, India
| | - Sharad D Iyengar
- Action Research & Training for Health (ARTH), Satyam, Ramgiri, Badgaon, Udaipur, Rajasthan, 313011, India
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, 20 Avenue Appia, 1211, Geneva-27, Switzerland
| | - Heidi Bart Johnston
- Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box 4002, Basel, Switzerland
| | - Kirti Iyengar
- Action Research & Training for Health (ARTH), Satyam, Ramgiri, Badgaon, Udaipur, Rajasthan, 313011, India. .,Department of Women's and Children's Health, Karolinska Institutet, WHO collaborating Centre, Karolinska University Hospital, SE-17176, Stockholm, Sweden.
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