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A time motion study of community mental health workers in rural India.

ABSTRACT: BACKGROUND:Community Health Workers (CHWs) are critical to providing healthcare services in countries such as India which face a severe shortage of skilled healthcare personnel especially in rural areas. The aim of this study is to understand the work flow of CHWs in a rural Community Mental Health Project (CMHP) in India and identify inefficiencies which impede their service delivery. This will aid in formulating a targeted policy approach, improving efficiency and supporting appropriate work allocation as the roles and responsibilities of the CHWs evolve. METHODS:A continuous observation Time Motion study was conducted on Community Health Workers selected through purposive sampling. The CHWs were observed for the duration of an entire working day (9?am- 3?pm) for 5 days each, staggered during a period of 1 month. The 14 different activities performed by the CHWs were identified and the time duration was recorded. Activities were then classified as value added, non-value added but necessary and non-value-added to determine their time allocation. RESULTS:Home visits occupied the CHWs for the maximum number of hours followed by Documentation, and Traveling. Documentation, Administrative work and Review of work process are the non-value-added but necessary activities which consumed a significant proportion of their time. The CHWs spent approximately 40% of their time on value added, 58.5% of their time on non-value added but necessary and 1.5% of their time on non-value added activities. The CHWs worked for 0.7?h beyond the stipulated time daily. CONCLUSION:The CHW's are "dedicated" mental health workers as opposed to being "generalists" and their activities involve a significant investment of their time due to the specialized nature of the services offered such as counselling, screening and home visits. The CHWs are stretched beyond their standard work hours. Non-value added but necessary activities consumed a significant proportion of their time at the expense of value-added activities. Work flow redesign and implementation of Health Management Information Systems (HMIS) can mitigate inefficiencies.

SUBMITTER: Chebolu-Subramanian V

PROVIDER: S-EPMC6873675 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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A time motion study of community mental health workers in rural India.

Chebolu-Subramanian Vijaya V Sule Nachiket N Sharma Richa R Mistry Nerges N

BMC health services research 20191121 1

<h4>Background</h4>Community Health Workers (CHWs) are critical to providing healthcare services in countries such as India which face a severe shortage of skilled healthcare personnel especially in rural areas. The aim of this study is to understand the work flow of CHWs in a rural Community Mental Health Project (CMHP) in India and identify inefficiencies which impede their service delivery. This will aid in formulating a targeted policy approach, improving efficiency and supporting appropriat ...[more]

PMID: 31752869

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Project description:IntroductionCommunity health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi.MethodsWe conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks.ResultsWe observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05).ConclusionThis study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.

Project description:BackgroundDespite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India.MethodsWe conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach.ResultsHome visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss.ConclusionsThe study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.

Project description:BackgroundCommunity health workers (CHWs) are essential field-based personnel and increasingly used to deliver priority interventions to achieve universal health coverage. Existing literature allude to the potential for detrimental effects of multi-tasking CHWs. This study objective was to assess the impact of integrating cervical cancer screening and prevention therapy (CCSPT) with family planning (FP) on time utilization among CHWs.MethodsA time and motion study was conducted in 7 health facilities in Malawi. Data was collected at baseline between October-July 2019, and 12 months after CCSPT implementation between July and August 2021. CHWs trained to deliver CCSPT were continuously observed in real time while their activities were timed by independent observers. We used paired sample t-test to assess pre-post differences in average hours CHWs spent on the following key activities, before and after CCSPT implementation: clinical and preventive care; administration; FP; and non-work-related tasks. Regression models were used to ascertain impact of CCSPT on average durations CHWs spent on key activities.ResultsThirty-seven (n = 37) CHWs were observed. Their mean age and years of experience were 42 and 17, respectively. Overall, CHWs were observed for 323 hours (inter quartile range: 2.8-5.5). Compared with the period before CCSPT, the proportion of hours CHWs spent on clinical and preventive care, administration and non-work-related activities were reduced by 13.7, 8.7 and 34.6%, respectively. CHWs spent 75% more time on FP services after CCSPT integration relative to the period before CCSPT. The provision of CCSPT resulted in less time that CHWs devoted towards clinical and preventive care but this reduction was not significant. Following CCPST, CHWs spent significantly few hours on non-work-related activities.ConclusionIntroduction of CCSPT was not very detrimental to pre-existing community services. CHWs managed their time ensuring additional efforts required for CCSPT were not at the expense of essential activities. The programming and policy implications are that multi-tasking CHWs with CCSPT will not have substantial opportunity costs.

Project description:ObjectiveThe main objective of this exploratory study was to investigate the overlooked perspectives and beliefs of Accredited Social Health Activists (ASHA workers) regarding a collaborative care mental health intervention (HOPE: Healthier Options through Empowerment), mental illness and the health of their rural communities.DesignSemi-structured, one-on-one, qualitative interviews.SettingSeven primary health centres (PHCs) in rural Karnataka, India. All PHCs had previously completed the HOPE study.Participants15 ASHA workers, selected via purposive sampling. ASHAs are high school-educated village women trained as community health workers. ASHAs were included if they had previously participated in the HOPE intervention, a collaborative-care randomised controlled trial that aimed to integrate mental healthcare into existing primary care systems in rural Karnataka.InterventionsNo interventions were introduced.ResultsASHA workers mostly had positive interactions with patients, including encouraging them to attend sessions, helping to explain the topics and techniques, and checking on the patients frequently. ASHA workers were able to identify key barriers to treatment and facilitators to treatment. ASHAs claimed that their knowledge about mental illness improved because of the HOPE study, though gaps remained in their understanding of aetiology and treatment. Several expressed interest in receiving additional mental health training. Overall, ASHAs viewed the HOPE study as a necessary and effective intervention, and requested that it expand.ConclusionsThis paper discusses the perspectives of ASHAs who participated in a novel effort to extend the collaborative care model to their own communities. ASHA workers help maintain relationships with patients that encourage participation, and the efforts of ASHAs often aid in mitigating common barriers to treatment. ASHA workers' beliefs and knowledge regarding mental illness can be changed, and ASHAs can become effective advocates for patients. Future collaborative care interventions would likely benefit from involving ASHA workers in community outreach efforts.

Project description:Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.

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A time motion study of community mental health workers in rural India.

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A time motion study of community mental health workers in rural India.

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