The amount and value of work time of community medicine distributors in community case management of malaria among children under five years in the Ejisu-Juaben District of Ghana

Determinants of mobile health (M-Health) application adoption, usage and discontinuity among corporate workers diagnosed with hypertension and diabetes

PURPOSE

This study examined the determinants of mobile health (M-Health) application, adoption, usage and discontinuation among corporate workers diagnosed with hypertension and diabetes in Ghana.

DESIGN/METHODOLOGY/APPROACH

The diffusion innovation and reasoned action theories were employed using an exploratory design. Three hundred corporate workers diagnosed with diabetes and hypertension from three health facilities for the past six months were sampled for the study using a multi-stage sampling technique and administered questionnaires. Descriptive statistics and logistic regression tools were employed in the analysis of data.

FINDINGS

The study found a significant number of factors influencing m-health applications adoption, usage and discontinuity. These factors include nature and demand of job, perceived advantage, compatibility, complexity, triability, aesthetics and trust. Aesthetics emerged as the strongest predictive factor for the adoption, usage and discontinuity of use among diabetic and hypertensive corporate workers. With the adoption of M-Health applications, compatibility, as well as nature and demand of job, were significant predictors. With the usage of M-Health applications, complexity, triability, aesthetics and trust were significant predictors. Moreover, perceived advantage, compatibility, complexity and triability influenced significantly the choice to discontinue using M-Health applications. The study concluded that M-Health application functionalities play a valuable role in patients' intention to adopt, use and discontinue the use of an M-Health application in Ghana.

ORIGINALITY/VALUE

This exploratory study offers in-depth insight into how major M-Health application features affect its adoption, usage and discontinuity, providing crucial information for future research and the improvement of chronic condition healthcare delivery.

Emergence of the Coexistence of mcr-1, bla NDM-5, and bla CTX-M-55 in Klebsiella pneumoniae ST485 Clinical Isolates in China

Introduction

Polymyxin resistance caused by the plasmid-mediated mcr-1 gene in gram-negative bacilli poses a huge threat to our health. In recent years, many regions have reported that mcr-1 and β-lactamase genes can coexist in a single strain.

Methods

In this study, 107 nonduplicate Klebsiella pneumoniae (K. pneumoniae) isolates were collected from a tertiary hospital in Jiangxi, China. Antimicrobial susceptibility testing of isolates was performed using gram-negative susceptibility cards on the VITEK system. The minimum inhibitory concentrations (MICs) of polymyxin B was detected using the microdilution broth method. The presence of resistance genes was assessed using polymerase chain reaction (PCR). We subjected isolates to genotyping using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) and analyzed the transferability of plasmids with filter mating and electroporation. Subsequently, whole-genome sequencing was performed for plasmids.

Results

Of the 107 K. pneumoniae isolates, 15 (14.0%) were resistant to polymyxin B. All polymyxin B-resistant isolates harbored at least one of the extended-spectrum β-lactamase genes tested. Only one isolate simultaneously harbored mcr-1, bla_NDM-5, bla_CTX-M-55 , and bla_SHV-27 genes. MLST results showed that 15 carbapenem-resistant K. pneumoniae isolates belonged to five sequence types (STs). PFGE results displayed nine different PFGE clusters. Conjugation and transformation experiments and sequencing analysis showed that the strain had three plasmids, and mcr-1, bla_NDM-5 , and bla_CTX-M-55 were located on different plasmids.

Conclusion

The present study demonstrated for the first time the coexistence of mcr-1, bla_NDM-5 , and bla_CTX-M-55 in a K. pneumoniae ST485 isolate. The three plasmids carrying the mcr-1, bla_NDM-5 , and bla_CTX-M-55 genes can be transmitted in Enterobacteriaceae strains, which may lead to more severe bacterial resistance.

Mobile phone use and the welfare of community health nurses in Ghana: An analysis of unintended costs

The use of mobile phones is fast transforming the healthcare delivery landscape in Ghana. A substantial number of health facilities are now dependent on mobile phones to facilitate their work. Evidence of the use of mobile phones in Ghana's healthcare is however limited. In order to contribute to the evidence of the value of using mobile phones to promote healthcare, we interrogated and highlighted unexpected costs imposed on community health nurses who use their personal mobile phones for healthcare delivery in the country. Data for the study were derived from 598 completed questionnaires and extracts from focus group discussions with community health nurses who were sampled from three regions across the three main ecological zones of Ghana. The results show that over 90% of nurses bear the cost of paying for airtime, bundles and chargers used for work-related activities, yet less than 10% of them receive direct compensation. This costly burden has the potential to demotivate the nurses and threaten the country's progress towards the achievement of universal health coverage. More significantly, the data strongly suggest that physical distance, regional location and gender are the main factors triggering extra costs incurred by the nurses. We conclude that the use of personal mobile phones for healthcare delivery imposed huge financial burden on community health workers in Ghana. A suggested intervention to forestall negative consequences on performance is to offer incentive packages to nurses as a compensation for the financial and non-physical costs of using personal mobile phones for work-related activities.

"From experts to locals hands" healthcare service planning in sub-Saharan Africa: an insight from the integrated community case management of Ghana

Background

Although community participation remains an essential component globally in healthcare service planning, evidence of how rural communities participate in the planning of rural-based healthcare programs has less been explored in Sub-Saharan Africa.

Objective

We explored communities’ participation in health care planning in hard-to-reach communities, within the context of Integrated Community Case Management (iCCM), a community-based health program implemented in Ghana.

Methods

Qualitative data were collected from eleven (11) hard-to-reach communities through Focus Group Discussions (FGDs), Key Informant Interviews (KIIs) as well as district-level studies (Nadowli-Kaleo, and WA East districts of Ghana). The Rifkin’s spider-gram, framework, for measuring and evaluating community participation in healthcare planning was adapted for the study.

The results

The study found that community participation was superficially conducted by the CHOs. A holistic community needs assessment to create awareness, foster a common understanding of health situations, collaboration, acceptance and ownership of the program were indiscernible. Rather, it took the form of an event, expert-led-definition, devoid of coherence to build locals understanding to gain their support as beneficiaries of the program. Consequently, some of the key requirements of the program, such as resource mobilization by rural residents, Community-based monitoring of the program and the act of leadership towards sustainability of the program were not explicitly found in the beneficiaries’ communities.

Conclusion and recommendation

The study concludes that there is a need to expand the concept of community involvement in iCCM to facilitate communities’ contribution to their healthcare. Also, a transdisciplinary approach is required for engineering and scaling up community-based health programs, empowering VHCs, CBHVs and CHAs to realize success.

Quantifying and Valuing Community Health Worker Time in Improving Access to Malaria Diagnosis and Treatment

Background. Community health workers (CHWs) are members of a community who are chosen by their communities as first-line, volunteer health workers. The time they spend providing healthcare and the value of this time are often not evaluated. Our aim was to quantify the time CHWs spent on providing healthcare before and during the implementation of an integrated program of diagnosis and treatment of febrile illness in 3 African countries.

Methods. In Burkina Faso, Nigeria, and Uganda, CHWs were trained to assess and manage febrile patients in keeping with Integrated Management of Childhood Illness recommendations to use rapid diagnostic tests, artemisinin-based combination therapy, and rectal artesunate for malaria treatment. All CHWs provided healthcare only to young children usually <5 years of age, and hence daily time allocation of their time to child healthcare was documented for 1 day (in the high malaria season) before the intervention and at several time points following the implementation of the intervention. Time spent in providing child healthcare was valued in earnings of persons with similar experience.

Results. During the high malaria season of the intervention, CHWs spent nearly 50 minutes more in daily healthcare provision (average daily time, 30.2 minutes before the intervention vs 79.5 minutes during the intervention; test for difference in means P < .01). On average, the daily time spent providing healthcare during the intervention was 55.8 minutes (Burkina Faso), 77.4 minutes (Nigeria), and 72.2 minutes (Uganda). Using the country minimum monthly salary, CHWs’ time allocated to child healthcare for 1 year was valued at US Dollars (USD) $52 in Burkina Faso, USD $295 in Nigeria, and USD $141 in Uganda.

Conclusions. CHWs spend up to an hour and a half daily on child healthcare in their communities. These data are informative in designing reward systems to motivate CHWs to continue providing good-quality services.

Clinical Trials Registration. ISRCTN13858170.

Community health workers in Ghana: the need for greater policy attention

From the 1970s to the 1990s, the WHO, United Nations and other agencies mooted the idea of formally training and recognising community health workers (CHWs) to complement efforts to improve primary healthcare delivery in low and middle income countries. Recently, CHWs have been recognised as important players in the achievement of the health-related Millennium Development Goals (MDGs). Despite this recognition, little understanding exists in Ghana about the activities of CHWs: who they are; how they are recruited; what they do; level of health policy support; contribution to healthcare delivery and the challenges they face. Based on a rapid scoping review of the existing literature, and our experience working in Ghana, this paper reflects on the role of CHWs in healthcare delivery in Ghana. We argue that CHWs have played critical roles in improving health service delivery and outcomes, including guinea worm eradication, expanded immunisation coverage, maternal and child health, and HIV/AIDS treatment and management. However, these achievements notwithstanding, CHWs face challenges which prevent them from being optimally productive, including capacity problems, neglect by the healthcare system, high attrition rates and inadequate supervision. Policymakers in Ghana therefore need to give increased attention to CHWs, provide remuneration for their activities, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities.

A mixed methods approach to evaluating community drug distributor performance in the control of neglected tropical diseases

Background

Trusted literate, or semi-literate, community drug distributors (CDDs) are the primary implementers in integrated preventive chemotherapy (IPC) programmes for Neglected Tropical Disease (NTD) control. The CDDs are responsible for safely distributing drugs and for galvanising communities to repeatedly, often over many years, receive annual treatment, create and update treatment registers, monitor for side-effects and compile treatment coverage reports. These individuals are ‘volunteers’ for the programmes and do not receive remuneration for their annual work commitment.

Methods

A mixed methods approach, which included pictorial diaries to prospectively record CDD use of time, structured interviews and focus group discussions, was used to triangulate data on how 58 CDDs allocated their time towards their routine family activities and to NTD Programme activities in Uganda. The opportunity costs of CDD time were valued, performance assessed by determining the relationship between time and programme coverage, and CDD motivation for participating in the programme was explored.

Results

Key findings showed approximately 2.5 working weeks (range 0.6–11.4 working weeks) were spent on NTD Programme activities per year. The amount of time on NTD control activities significantly increased between the one and three deliveries that were required within an IPC campaign. CDD time spent on NTD Programme activities significantly reduced time available for subsistence and income generating engagements. As CDDs took more time to complete NTD Programme activities, their treatment performance, in terms of validated coverage, significantly decreased. Motivation for the programme was reported as low and CDDs felt undervalued.

Conclusions

CDDs contribute a considerable amount of opportunity cost to the overall economic cost of the NTD Programme in Uganda due to the commitment of their time. Nevertheless, programme coverage of at least 75 %, as required by the World Health Organisation, is not being achieved and vulnerable individuals may not have access to treatment as a consequence of sub-optimal performance by the CDDs due to workload and programmatic factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1606-2) contains supplementary material, which is available to authorized users.

Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa

Community health worker (CHW) programmes are currently being scaled-up in sub-Saharan Africa to improve access to healthcare. CHWs are often volunteers; from an economic perspective, this raises considerations whether reliance on an unpaid workforce is sustainable and how to appropriately cost and value the work of CHWs. Both these questions can be informed by an understanding of CHWs' workload, their opportunity costs of time and the perceived benefits of being a CHW. However, to date few studies have fully explored the methodological challenges in valuing CHW time. We examined the costs and benefits of volunteering in a sample of 45 CHWs providing integrated community case management of common childhood illnesses in rural Uganda in February 2012 using different methods. We assessed the value of CHW time using the minimum public sector salary rate and a CHW-elicited replacement wage, as well as the opportunity cost of time based on CHW-estimated annual income and alternative work opportunities, respectively. Reported monthly CHW workload, a median of 19.3 h (range 2.5-57), was valued at USD 6.9 (range 0.9-20.4) per month from the perspective of the healthcare system (applicable replacement wage) and at a median of USD 4.1 (range 0.4-169) from the perspective of the CHWs (individual opportunity cost of time). In a discrete choice experiment on preferred work characteristics, remuneration and community appreciation dominated. We find that volunteering CHWs value the opportunity to make a social contribution, but the decision to volunteer is also influenced by anticipated future rewards. Care must be taken by those costing and designing CHW programmes to acknowledge the opportunity cost of CHWs at the margin and over the long term. Failure to properly consider these issues may lead to cost estimations below the amount necessary to scale up and sustain programmes.

Malaria community health workers in Myanmar: a cost analysis

Background

Myanmar has the highest malaria incidence and attributed mortality in South East Asia with limited healthcare infrastructure to manage this burden. Establishing malaria Community Health Worker (CHW) programmes is one possible strategy to improve access to malaria diagnosis and treatment, particularly in remote areas. Despite considerable donor support for implementing CHW programmes in Myanmar, the cost implications are not well understood.

Methods

An ingredients based micro-costing approach was used to develop a model of the annual implementation cost of malaria CHWs in Myanmar. A cost model was constructed based on activity centres comprising of training, patient malaria services, monitoring and supervision, programme management, overheads and incentives. The model takes a provider perspective. Financial data on CHWs programmes were obtained from the 2013 financial reports of the Three Millennium Development Goal fund implementing partners that have been working on malaria control and elimination in Myanmar. Sensitivity and scenario analyses were undertaken to outline parameter uncertainty and explore changes to programme cost for key assumptions.

Results

The range of total annual costs for the support of one CHW was US$ 966–2486. The largest driver of CHW cost was monitoring and supervision (31–60 % of annual CHW cost). Other important determinants of cost included programme management (15–28 % of annual CHW cost) and patient services (6–12 % of annual CHW cost). Within patient services, malaria rapid diagnostic tests are the major contributor to cost (64 % of patient service costs).

Conclusion

The annual cost of a malaria CHW in Myanmar varies considerably depending on the context and the design of the programme, in particular remoteness and the approach to monitoring and evaluation. The estimates provide information to policy makers and CHW programme planners in Myanmar as well as supporting economic evaluations of their cost-effectiveness.

Estimating the cost of referral and willingness to pay for referral to higher-level health facilities: a case series study from an integrated community case management programme in Uganda

Background

Integrated community case management (iCCM) relies on community health workers (CHWs) managing children with malaria, pneumonia, diarrhoea, and referring children when management is not possible. This study sought to establish the cost per sick child referred to seek care from a higher-level health facility by a CHW and to estimate caregivers’ willingness to pay (WTP) for referral.

Methods

Caregivers of 203 randomly selected children referred to higher-level health facilities by CHWs were interviewed in four Midwestern Uganda districts. Questionnaires and document reviews were used to capture direct, indirect and opportunity costs incurred by caregivers, CHWs and health facilities managing referred children. WTP for referral was assessed through the ‘bidding game’ approach followed by an open-ended question on maximum WTP. Descriptive analysis was conducted for factors associated with referral completion and WTP using logistic and linear regression methods, respectively. The cost per case referred to higher-level health facilities was computed from a societal perspective.

Results

Reasons for referral included having fever with a negative malaria test (46.8 %), danger signs (29.6 %) and drug shortage (37.4 %). Among the referred, less than half completed referral (45.8 %). Referral completion was 2.8 times higher among children with danger signs (p = 0.004) relative to those without danger signs, and 0.27 times lower among children who received pre-referral treatment (p < 0.001). The average cost per case referred was US$ 4.89 and US$7.35 per case completing referral. For each unit cost per case referred, caregiver out of pocket expenditure contributed 33.7 %, caregivers’ and CHWs’ opportunity costs contributed 29.2 % and 5.1 % respectively and health facility costs contributed 39.6 %.

The mean (SD) out of pocket expenditure was US$1.65 (3.25). The mean WTP for referral was US$8.25 (14.70) and was positively associated with having received pre-referral treatment, completing referral and increasing caregiver education level.

Conclusion

The mean WTP for referral was higher than the average out of pocket expenditure. This, along with suboptimal referral completion, points to barriers in access to higher-level facilities as the primary cause of low referral. Community mobilisation for uptake of referral is necessary if the policy of referring children to the nearest health facility is to be effective.

Community health workers and stand-alone or integrated case management of malaria: a systematic literature review

A systematic literature review was conducted to assess the effectiveness of strategies to improve community case management (CCM) of malaria. Forty-three studies were included; most (38) reported indicators of community health worker (CHW) performance, 14 reported on malaria CCM integrated with other child health interventions, 16 reported on health system capacity, and 13 reported on referral. The CHWs are able to provide good quality malaria care, including performing procedures such as rapid diagnostic tests. Appropriate training, clear guidelines, and regular supportive supervision are important facilitating factors. Crucial to sustainable success of CHW programs is strengthening health system capacity to support commodity supply, supervision, and appropriate treatment of referred cases. The little evidence available on referral from community to health facility level suggests that this is an area that needs priority attention. The studies of integrated CCM suggest that additional tasks do not reduce the quality of malaria CCM provided sufficient training and supervision is maintained.