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Community and health staff perceptions on non-communicable disease management in El Salvador's health system: a qualitative study.

ABSTRACT: BACKGROUND:Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability with a rising burden in low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, implies the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This study aims to describe the different stakeholders' perceptions about the management of NCDs along the pathways of care in this health system. METHODS:During three fieldwork periods in 2018, three complementary qualitative data collection methods were deployed and conducted in settings with high prevalence of NCDs within El Salvador. First, illness narrative methodology was used to document the life histories of people living with a chronic disease and being treated in second and third level health facilities. Second, through social mapping, support resources that NCD patients used throughout the process of their illness within the same settings were analysed. Third, semi-structured interviews were conducted in the same locations, with both chronic patients and health personnel working at different levels of the primary health care setting. Participants were recruited through purposive and snowball sampling, and a deductive approach was implemented for coding during the analysis phase. After grouping codes into potential themes, a thematic framework was developed using a reflexive approach and following triangulation of the data. RESULTS:This innovative approach of combining three well-defined qualitative methods identified key implications for the implementation of a comprehensive approach to NCD management in resource-poor settings. The following elements are identified: 1) social risk factors and barriers to care; 2) patient pathways to NCD care; 3) available resources identified through social connections mapping; 4) trust in social connections; and 5) community health promotion and NCD prevention management. CONCLUSIONS:The Salvadoran public health system has been able to strengthen its comprehensive approach to NCDs, combining a clinical approach - including long-term follow-up - with a preventive community-based strategy. The structural collaboration between the health system and the (self-) organised community has been essential for identifying failings, discuss tensions and work out adapted solutions.

SUBMITTER: Vidal N

PROVIDER: S-EPMC7251854 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Community and health staff perceptions on non-communicable disease management in El Salvador's health system: a qualitative study.

Vidal Nicole N León-García Montserrat M Jiménez Marta M Bermúdez Keven K De Vos Pol P

BMC health services research 20200527 1

<h4>Background</h4>Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability with a rising burden in low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, implies the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This study aims to describe the different stakeholders' perceptions ...[more]

PMID: 32460769

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Project description:BACKGROUND:One of today's greatest challenges in public health worldwide - and especially its key management from Primary Health Care (PHC) - is the growing burden of non-communicable diseases (NCDs). In El Salvador, since 2009 the Minister of Health (MoH) has scaled up a national public health system based on a comprehensive PHC approach. A national multi-sectorial strategic plan for a comprehensive approach to NCDs has also been developed. This analysis explores stakeholders' perceptions related to the management of NCDs in PHC and, in particular, the role of social participation. METHODS:A case-study was developed consisting of semi structured interviews and official document reviews. Semi-structured interviews were developed with chronic patients (14) and PHC professionals working in different levels within PHC (12). Purposive sampling was used to recruit participants. A non-pure, deductive approach was implemented for coding. After grouping codes into potential themes, a thematic framework was elaborated through a reflexive approach and the triangulation of the data. The research was conducted between March and August of 2018 in three different departments of El Salvador. RESULTS:The structure and the functioning of the Salvadoran PHC system and its intersectoral approach is firstly described. The interdisciplinary PHC-team brings holistic health care closer to the communities in which health promoters play a key role. The findings reflect the generally positive perception of the PHC system in terms of accessibility, quality and continuity of care by chronic patients. Community engagement and the National Health Forum are ensuring accountability through social controllership mechanisms. However, certain challenges were also noted during the interviews related to the shortage of medication and workforce; coordination between the levels of care and the importance of prevention and health promotion programmes for NCDs. CONCLUSIONS:The Salvadoran PHC and its comprehensive approach to NCDs with an emphasis on intersectoral participation has been positively perceived by the range of stakeholders interviewed. Social engagement and the NHF works as a driving force to ensure accountability as well as in the promotion of a preventive culture. The challenges identified provide keys to amplify knowledge for addressing inequalities in health by strengthening PHC and its NCDs management.

Project description:BackgroundIntegrated community case management (iCCM) involves delivery of simple medicines to children with pneumonia, diarrhea and/or malaria by community health workers (CHWs). Between 2010 and 2012, an iCCM intervention trial was implemented by Healthy Child Uganda. This study used qualitative tools to assess whether project stakeholders perceived that iCCM improved access to care for children under five years of age.MethodsThe intervention involved training and equipping 196 CHWs in 98 study villages in one sub-county in Uganda in iCCM. During the eight-month intervention, CHWs assessed sick children, provided antimalarials (coartem) for fever, antibiotics (amoxicillin) for cough and fast breathing, oral rehydration salts/zinc for diarrhea, and referred very sick children to health facilities. In order to examine community perceptions and acceptability of iCCM, post-intervention focus groups and key respondent interviews involving caregivers, health workers, CHWs and local leaders were carried out by experienced facilitators using semi-structured interview guides. Data were analyzed using thematic analysis techniques.ResultsRespondents reported increased access to health care for children as a result of iCCM. Access was reportedly closer to home, available more hours in a day, and the availability of CHWs was perceived as more reliable. CHW care was reported to be trustworthy and caring. Families reported saving money especially due to reduced transportation costs, and less time away from home. Respondents also perceived better health outcomes. Linkages between health facilities and communities were reportedly improved by the iCCM intervention due to the presence of trained CHWs in the community.ConclusionsiCCM delivered by CHWs may improve access to health care and is acceptable to families. Policymakers should continue to seek opportunities to implement and support iCCM, particularly in remote communities where there are health worker shortages.

Project description:BackgroundThe increasing burden of Non-Communicable Diseases (NCDs) in Bangladesh underscores the importance of strengthening primary health care systems. In this study, we examined the barriers and facilitators to engaging Community Health Workers (CHWs) for NCDs prevention and control in Bangladesh.MethodsWe used multipronged approaches, including a. Situation analyses using a literature review, key personnel and stakeholders' consultative meetings, and exploratory studies. A grounded theory approach was used for qualitative data collection from health facilities across three districts in Bangladesh. We conducted in-depth interviews with CHWs (Health Inspector; Community Health Care Provider; Health Assistant and Health Supervisor) (n = 4); key informant interviews with central level health policymakers/ managers (n = 15) and focus group discussions with CHWs (4 FGDs; total n = 29). Participants in a stakeholder consultative meeting included members from the government (n = 4), non-government organisations (n = 2), private sector (n = 1) and universities (n = 2). Coding of the qualitative data and identification of themes from the transcripts were carried out and thematic approach was used for data analyses.ResultsThe CHWs in Bangladesh deliver a wide range of public health programs. They also provide several NCDs specific services, including screening, provisional diagnosis, and health education and counselling for common NCDs, dispensing basic medications, and referral to relevant health facilities. These services are being delivered from the sub-district health facility, community clinics and urban health clinics. The participants identified key challenges and barriers, which include lack of NCD specific guidelines, inadequate training, excessive workload, inadequate systems-level support, and lack of logistics supplies and drugs. Yet, the facilitating factors to engaging CHWs included government commitment and program priority, development of NCD related policies and strategies, establishment of NCD corners, community support systems, social recognition of health care staff and their motivation.ConclusionEngaging CHWs has been a key driver to NCDs services delivery in Bangladesh. However, there is a need for building capacity of CHWs, maximizing CHWs engagement to NCD services delivery, facilitating systems-level support and strengthening partnerships with non-state sectors would be effective in prevention and control efforts of NCDs in Bangladesh.

Project description:Background/objectiveThe increasing burden of non-communicable diseases (NCDs) in Nepal underscores the importance of strengthening primary healthcare systems to deliver efficient care. In this study, we examined the barriers and facilitators to engaging community health workers (CHWs) for NCDs prevention and control in Nepal.DesignWe used multiple approaches including (a) review of relevant literature, (b) key personnel and stakeholders' consultation meetings and (c) qualitative data collection using semistructured interviews. A grounded theory approach was used for qualitative data collection and the data were analysed thematically.SettingData were collected from health facilities across four districts in Nepal and two stakeholder consultative meetings were conducted at central level.ParticipantsWe conducted in-depth interviews with CHWs (Health Assistants, Auxiliary Health Workers, Auxiliary Nurse Midwife) (n=5); key informant interviews with health policymakers/managers (n=3) and focus group discussions (FGDs) with CHWs (four FGDs; total n=27). Participants in two stakeholder consultative meetings included members from the government (n=8), non-government organisations (n=7), private sector (n=3) and universities (n=6).ResultsThe CHWs were engaged in a wide range of public health programmes and they also deliver NCDs specific programmes such as common NCDs screening, provisional diagnosis, primary care, health education and counselling, basic medication and referral and so on. These NCD prevention and control services are concentrated in those districts, where the WHO, Package for prevention and control of NCDs) program is being implemented. Some challenges and barriers were identified, including inadequate NCD training, high workload, poor system-level support, inadequate remuneration, inadequate supply of logistics and drugs. The facilitating factors included government priority, formation of NCD-related policies, community support systems, social prestige and staff motivation.ConclusionEngaging CHWs has been considered as key driver to delivering NCDs related services in Nepal. Effective integration of CHWs within the primary care system is essential for CHW's capacity buildings, necessary supervisory arrangements, supply of logistics and medications and setting up effective recording and reporting systems for prevention and control of NCDs in Nepal.

Project description:IntroductionNon-communicable diseases (NCDs) have recently become a global public health burden and a leading cause of premature death, mainly in low- and middle-income countries (LMICs). The aim of the study was to explore physicians' perceptions on the availability and quality of clinical care for the management of NCDs.MethodsThis was a qualitative exploratory study meant to obtain expert perceptions on clinical care delivery for NCDs in one Zimbabwean central hospital setting. Data was collected from participants who consented and was analyzed using Stata version 13. A four-point Likert scale was used to categorize different levels of perceived satisfaction.FindingsTwenty-three doctors participated in the study: four female doctors and nineteen males. Nineteen of the doctors were general practitioners, whilst four were specialists. The findings indicated that both categories perceived some shortfalls in clinical care for NCDs. Moreover, the perceptions of general practitioners and specialists were not significantly different. Participants perceived cancer care to be lagging far behind the other three NCDs under study. Care of cardiovascular diseases (CVDs) and diabetes showed mixed perceptions amongst participants, with positive perceptions almost equaling negative perceptions. Furthermore, hypertension was perceived to be clinically cared for better than the other NCDs under consideration. Reasons for the gaps in NCD clinical care were attributed by 33% of the participants to financial challenges; a further 27% to patient behavioral challenges; and 21% to communication challenges.ConclusionsThe article concludes that care delivery for the selected NCDs under study at CCH need to be improved. Furthermore, it is crucial to diagnose NCDs before patients show clinical symptoms. This helps disease prognosis to yield better care results. The evaluation of doctors' perceptions indicates the need to improve NCD care at the institution in order to control NCD co-morbidities that may increase mortality.

Project description:In Kenya, noncommunicable diseases (NCDs) account for 27% of all deaths. Adult Kenyans have an 18% chance of dying prematurely from cancers, diabetes, cardiovascular diseases or chronic respiratory diseases. A Novartis Access Initiative is making medicines available to treat cardiovascular diseases, diabetes, chronic respiratory diseases, and breast cancer in 30 countries, including Kenya. Little is known about patients' perceptions of access to medicines for NCDs in Kenya. The study objective was to understand patients' perceptions of access to medicines; as well as barriers and facilitators at the household, community, and healthcare system level. A baseline qualitative study was conducted in eight of 47 counties as part of an evaluation of the Novartis Access Initiative in Kenya. The 84 patients interviewed through a household survey had been diagnosed and treated for an NCD. Although medicines at government facilities were free or cheaper than those sold in private pharmacies, the availability of medicines presented a constant challenge. Patients often resorted to private pharmacies, where NCD medicines cost more than at public facilities. Participants with an NCD took their health seriously and strove to get the medicines, even under difficult circumstances. Buying NCD medicines put a strain on the household budget, especially for the lower-income participants. Some actions to overcome affordability barriers included: borrowing money, selling assets, seeking help from relatives, taking on extra work, buying partial dosages, leaving without the medicines, or resorting to non-medical alternatives. In conclusion, access to NCD medicines is a major challenge for most adults in Kenya. As a result, they engage in complex interactions between public, private facilities and pharmacies to overcome the barriers. The government should ensure well-stocked public sector pharmacies and subsidize prices of medicines for lower-income patients. Integration of industry-led access to medicine programs may help governments to obtain low cost supplies.

Project description:BackgroundMonitoring trends in community opinion can identify critical opportunities to implement upstream health policies or interventions. Our study examines change and demographic modifiers of change in community perceptions of government intervention for prevention of lifestyle-related chronic disease across two time points in Australia.MethodsData were drawn from the 2016 (n = 2052) and 2018 (n = 2601) waves of a nationally representative cross-sectional telephone survey, 'AUSPOPS'. Survey questions gauged perceptions of government intervention for health in general, peoples'/organizations' role in maintaining health (e.g., parents, government) and support for specific health interventions (e.g., taxing soft drink). Bivariate and multivariate regression models tested for change between the two surveys, adjusted for demographic characteristics. Models with interactions between survey wave and demographic variables tested for differential change. One-tailed variance ratio tests examined whether opinions had become more polarized in 2018 compared with 2016.ResultsThe large, significant increase observed in the perceived size of the role that government has in maintaining people's health was uniform across demographic subpopulations. The role for employers and private health insurers was also perceived to be larger in 2018 compared with 2016, but the degree of change varied by gender, age and/or socioeconomic status. Support for some government interventions (e.g., taxing soft drinks) increased among specific demographic subgroups whilst exhibiting no overall change. Opinion was more polarized on general attitudes to government intervention for population health in 2018 compared to 2016, despite little change in central tendency.ConclusionsOpportunities may exist to implement government health-promoting policies (e.g., taxing soft drinks), although advocacy may be needed to address the concerns of less supportive subpopulations. Attitudes on government intervention in general may be becoming more polarized; future research examining the association of such changes with exposure to different information sources could inform communication strategies for future health policy change.

Project description:Knowledge and practices of rural South African populations with regard to antibiotic access and use (ABACUS) remain understudied. By using the case of four villages in the north east of the country, our aim was to investigate popular notions and social practices related to antibiotics to inform patient-level social interventions for appropriate antibiotic use. To achieve this, we investigated where community members (village residents) were accessing and sourcing medication, and what they understood antibiotics and antibiotic resistance (ABR) to be. Embedded within the multicountry ABACUS project, this qualitative study uses interviews and focus group discussions. A sample of 60 community members was recruited from the Agincourt Health and Demographic Surveillance System, situated in Mpumalanga Province, from April to August, 2017. We used the five abilities of seek, reach, pay, perceive, and engage in access to healthcare as proposed by Levesque's "Access to Healthcare" framework. Respondents reported accessing antibiotics prescribed from legal sources: by nurses at the government primary healthcare clinics or by private doctors dispensed by private pharmacists. No account of the illegal purchasing of antibiotics was described. There was a mix of people who finished their prescription according to the instructions and those who did not. Some people kept antibiotics for future episodes of infection. The concept of "ABR" was understood by some community members when translated into related Xitsonga words because of knowledge tuberculosis and HIV/AIDS treatment regimens. Our findings indicate that regulation around the sale of antibiotics is enforced. Safer use of antibiotics and why resistance is necessary to understand need to be instilled. Therefore, context-specific educational campaigns, drawing on people's understandings of antibiotics and informed by the experiences of other diseases, may be an important and deployable means of promoting the safe use of antibiotics.

Project description:IntroductionUrinary catheters are used extensively throughout healthcare for various reasons including management of urinary tract dysfunction. The purpose of this study was to simultaneously explore both catheter user experience and staff perception of catheter services within community urinary catheter care.MethodsA questionnaire was conducted to investigate the views of community nursing staff. During the same time period, patients were interviewed about i) catheter-care standards and adherence to guidelines ii) patients' feelings towards their catheter and iii) potential improvements to catheter practices and design.ResultsSixty-nine staff were surveyed. Although 97% of staff indicated they used local guidelines, in up to 62% of cases findings suggested practices in sending urine samples for culture did not comply with guidelines. Seventy-five percent of staff were satisfied with catheter care, but weaknesses were identified in handover processes, communication between staff and patients, and excessive documentation. Staff results were compared with the findings from interviews of 29 long-term urinary catheter users, demonstrating a higher level of satisfaction with catheter care amongst patients (86%). Patients and staff agreed that generally the impacts of their catheter on personal hygiene, sense of independence, sense of dignity and of patient happiness, were neutral (neither positive nor negative). However, regarding improvements to catheter practices and catheter design; 73% of staff but only 45% of patients suggested improvements in service, while 76% of patients but only 49% of staff suggested improvement in design.ConclusionThe study reveals general satisfaction with community catheter care, but indicates areas of potential improvements regarding communication, documentation and catheter design. When compared to patient responses, staff overall had a less positive view of patients perception of their relationship with their catheter.

Dataset Information

Community and health staff perceptions on non-communicable disease management in El Salvador's health system: a qualitative study.

Publications

Community and health staff perceptions on non-communicable disease management in El Salvador's health system: a qualitative study.

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