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Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review.

ABSTRACT: Introduction:Maternal health and the performance of health workers is a key concern in low- and middle-income countries. Mobile health technologies are reportedly able to improve workers' performance. However, how this has been achieved for maternal health workers in low-resource settings is not fully substantiated. To address this gap by building theoretical explanations, two questions were posed: How does mobile health influence the performance of maternal health care workers in low- and middle-income countries? What mechanisms and contextual factors are associated with mobile health use for maternal health service delivery in low- and middle-income countries? Methods:Guided by established guidelines, a realist review was conducted. Five databases were searched for relevant English language articles published between 2009 and 2016. A three-stage framework was developed and populated with explanatory configurations of Intervention-Context-Actors-Mechanism-Outcome. Articles were analyzed retroductively, with identified factors grouped into meaningful clusters. Results:Of 1254 records identified, 23 articles representing 16 studies were retained. Four main mechanisms were identified: usability and empowerment explaining mobile health adoption, third-party recognition explaining mobile health utilization, and empowerment of health workers explaining improved competence. Evidence was skewed toward the adoption and utilization stage of the framework, with weak explanations for performance outcomes. Conclusions:Findings suggest that health workers can be empowered to adopt and utilize mobile health in contexts where it is aligned to their needs, workload, training, and skills. In turn, mobile health can empower health workers with skills and confidence when it is perceived as useful and easy to use, in contexts that foster recognition from clients, peers, or supervisors.

SUBMITTER: Abejirinde IO

PROVIDER: S-EPMC6151957 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review.

Abejirinde Ibukun-Oluwa Omolade IO Ilozumba Onaedo O Marchal Bruno B Zweekhorst Marjolein M Dieleman Marjolein M

International journal of care coordination 20180619 3

<h4>Introduction</h4>Maternal health and the performance of health workers is a key concern in low- and middle-income countries. Mobile health technologies are reportedly able to improve workers' performance. However, <i>how</i> this has been achieved for maternal health workers in low-resource settings is not fully substantiated. To address this gap by building theoretical explanations, two questions were posed: How does mobile health influence the performance of maternal health care workers in ...[more]

PMID: 30271609

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Project description:BackgroundImproving health workers' performance is vital for achieving the Millennium Development Goals. In the literature on human resource management (HRM) interventions to improve health workers' performance in Low and Middle Income Countries (LMIC), hardly any attention has been paid to the question how HRM interventions might bring about outcomes and in which contexts. Such information is, however, critical to assess the transferability of results. Our aim was to explore if realist review of published primary research provides better insight into the functioning of HRM interventions in LMIC.MethodologyA realist review not only asks whether an intervention has shown to be effective, but also through which mechanisms an intervention produces outcomes and which contextual factors appear to be of critical influence. Forty-eight published studies were reviewed.ResultsThe results show that HRM interventions can improve health workers' performance, but that different contexts produce different outcomes. Critical implementation aspects were involvement of local authorities, communities and management; adaptation to the local situation; and active involvement of local staff to identify and implement solutions to problems. Mechanisms that triggered change were increased knowledge and skills, feeling obliged to change and health workers' motivation. Mechanisms to contribute to motivation were health workers' awareness of local problems and staff empowerment, gaining acceptance of new information and creating a sense of belonging and respect. In addition, staff was motivated by visible improvements in quality of care and salary supplements. Only a limited variety of HRM interventions have been evaluated in the health sector in LMIC. Assumptions underlying HRM interventions are usually not made explicit, hampering our understanding of how HRM interventions work.ConclusionApplication of a realist perspective allows identifying which HRM interventions might improve performance, under which circumstances, and for which groups of health workers. To be better able to contribute to an understanding of how HRM interventions could improve health workers' performance, a combination of qualitative and quantitative research methods would be needed and the use of common indicators for evaluation and a common reporting format would be required.

Project description:Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Project description:IntroductionHealth systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps.Methods and analysisIn this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses.Ethics and disseminationEthics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC).We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam.Prospero registration numberCRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200353.

Project description:OBJECTIVE:To systematically review and critically appraise the evidence for the effects of interventions to improve the performance of community health workers (CHWs) for community-based primary healthcare in low- and middle-income countries. DESIGN:Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS:19 electronic databases were searched with a highly sensitive prespecified strategy and the grey literature examined, completed July 2016. Randomised controlled trials evaluating interventions to improve CHW performance in low- and middle-income countries were included and appraised for risk of bias. Outcomes were biological and behavioural patient outcomes (primary), use of health services, quality of care provided by CHWs and CHW retention (secondary). RESULTS:Two reviewers screened 8082 records; 14 evaluations were included. Due to heterogeneity and lack of clear outcome data, no meta-analysis was conducted. Results were presented in a narrative summary. The review found one study showing no effect on the biological outcomes of interest, though these moderate quality data may not be indicative of all biological outcomes. It also found moderate quality evidence of the efficacy of performance improvement interventions for (1) improving behavioural outcomes for patients, (2) improving use of services by increasing the absolute number of patients who access services and, perhaps, better identifying those who would benefit from such services and (3) improving CHW quality of care in terms of upstream measures like completion of prescribed activities and downstream measures like adherence to treatment protocols. Nearly half of studies were compound interventions, making it difficult to isolate the effects of individual performance improvement intervention components, though four specific strategies pertaining to recruitment, supervision, incentivisation and equipment were identified. CONCLUSIONS:Variations in recruitment, supervision, incentivisation and equipment may improve CHW performance. Practitioners should, however, assess the relevance and feasibility of these strategies in their health setting prior to implementation. Component selection experiments on a greater range of interventions to improve performance ought to be conducted.

Project description:BackgroundDespite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers.MethodWe undertook a realist synthesis. An electronic search of five online databases (PubMed/Medline, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate Boolean phrases terms and selection procedures, 32 articles were identified. A theory-driven approach, narrative synthesis, was applied to synthesize the data. Thematic content analysis was used to delineate elements of the intervention, including its context, actors, mechanisms, and outcomes. Abduction and retroduction were applied using a realist evaluation heuristic tool to formulate generative theories.ResultsWe formulated two configurational models illustrating how and why mHealth impacts implementation and uptake of maternal and child health care. Implementation-related mechanisms include buy-in from health care providers, perceived support of health care providers' motivation and perceived ease of use and usefulness. These mechanisms are influenced by adaptive health system conditions including organization, resource availability, policy implementation dynamics, experience with technology, network infrastructure and connectivity. For pregnant women and mothers, mechanisms that trigger mHealth use and consequently uptake of maternal and child health care include perceived satisfaction, motivation and positive psychological support. Information overload was identified as a potential negative mechanism impacting the uptake of maternal and child health care. These mechanisms are influenced by health system conditions, socio-cultural characteristics, socio-economic and demographics characteristics, network infrastructure and connectivity and awareness.ConclusionModels developed in this study provide a detailed understanding of implementation and uptake of mHealth interventions and how and why they impact maternal and child health care in low- and middle-income countries. These models provide a foundation for the 'white box' of theory-driven evaluation of mHealth interventions and can improve rollout and implementation where required.

Project description:As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

Project description:BackgroundA key constraint to saturating coverage of interventions for reducing the burden of childhood illnesses in Low and Middle Income Countries (LMIC) is the lack of human resources. Community health workers (CHW) are potentially important actors in bridging this gap. Evidence exists on effectiveness of CHW in management of some childhood illnesses (IMCI). However, we need to know how and when this comes to be. We examine evidence from randomized control trials (RCT) on CHW interventions in IMCI in LMIC from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective.MethodsThe realist approach involves educing the mechanisms through which an intervention produced an outcome in a particular context. 'Mechanisms' are reactions, triggered by the interaction of the intervention and a certain context, which lead to change. These are often only implicit and are actually hypothesized by the reviewer. This review is limited to unravelling these from the RCTs; it is thus a hypothesis generating exercise.ResultsInterventions to improve CHW performance included 'Skills based training of CHW', 'Supervision and referral support from public health services', 'Positioning of CHW in the community'. When interventions were applied in context of CHW programs embedded in local health services, with beneficiaries who valued services and had unmet needs, the interventions worked if following mechanisms were triggered: anticipation of being valued by the community; perception of improvement in social status; sense of relatedness with beneficiaries and public services; increase in self esteem; sense of self efficacy and enactive mastery of tasks; sense of credibility, legitimacy and assurance that there was a system for back-up support. Studies also showed that if context differed, even with similar interventions, negative mechanisms could be triggered, compromising CHW performance.ConclusionThe aim of this review was to explore if RCTs could yield insight into the working of the interventions, when examined from a different, a realist perspective. We found that RCTs did yield some insight, but the hypotheses generated were very general and not well refined. These hypotheses need to be tested and refined in further studies.

Project description:Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

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Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review.

Publications

Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review.

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