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Valuing and Sustaining (or Not) the Ability of Volunteer Community Health Workers to Deliver Integrated Community Case Management in Northern Ghana: A Qualitative Study.

ABSTRACT: Within the integrated community case management of childhood illnesses (iCCM) programme, the traditional health promotion and prevention role of community health workers (CHWs) has been expanded to treatment. Understanding both the impact and the implementation experience of this expanded role are important. In evaluating UNICEF's implementation of iCCM, this qualitative case study explores the implementation experience in Ghana.Data were collected through a rapid appraisal using focus groups and individual interviews during a field visit in May 2013 to Accra and the Northern Region of Ghana. We sought to understand the experience of iCCM from the perspective of locally based UNICEF staff, their partners, researchers, Ghana health services management staff, CHWs and their supervisors, nurses in health facilities and mothers receiving the service. Our analysis of the findings showed that there is an appreciation both by mothers and by facility level staff for the contribution of CHWs. Appreciation was expressed for the localisation of the treatment of childhood illness, thus saving mothers from the effort and expense of having to seek treatment outside of the village. Despite an overall expression of value for the expanded role of CHWs, we also found that there were problems in supporting and sustaining their efforts. The data showed concern around CHWs being unpaid, poorly supervised, regularly out of stock, lacking in essential equipment and remaining outside the formal health system.Expanding the roles of CHWs is important and can be valuable, but contextual and health system factors threaten the sustainability of iCCM in Ghana. In this and other implementation sites, policymakers and key donors need to take into account historical lessons from the CHW literature, while exploring innovative and sustainable mechanisms to secure the programme as part of a government owned and government led strategy.

SUBMITTER: Daniels K

PROVIDER: S-EPMC4469587 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Project description:BackgroundHomecare workers provide essential care at home for people at end-of-life but are often poorly trained and supported.AimTo explore the experiences and needs of homecare workers and the views of homecare clients and carers, and other community-based health and social care staff about the homecare worker role, including identification of good practice.MethodsIn this qualitative exploratory study, we will conduct 150 semi-structured interviews with homecare workers within three geographic English localities chosen for maximum socio-demographic variation. Eligible participants will be consenting adults providing care services (workers [n = 45], managers [n = 15] community practitioners [n = 30]), receiving care (clients thought to be in the last 6 months of life [n = 30], family carers [n = 15], or commissioners of homecare services supporting end-of-life care [n = 15]. Interviews may adopt a Pictor-guided or standard semi-structured approach according to their preference. Managers and commissioners can contribute to an online focus group if preferred. A range of recruitment strategies will be used, including through homecare agencies, local authorities, local NHS services, charities, voluntary sector groups and social media. Interviews and focus groups will be recorded, transcribed, anonymised, and analysed adopting a case-based approach for each geographic area within-case and then comparison across cases using reflexive thematic analysis. The design and analysis will be informed by Bronfenbrenner's Adapted Ecological Systems theory. This study is registered on the Research Registry (No.8613).ContributionWe will provide evidence on ways to improve the experiences and address the needs of homecare workers in relation to caring for people nearing end-of-life. It will offer insight into good practice around supporting homecare workers including responding to their training and development needs. Findings will inform subsequent stages of an evaluation-phase study of a training resource for homecare workers.

Project description:ObjectiveAdherence to hypertension treatment is a major public health challenge for low and middle-income countries particularly in sub-Saharan Africa. One potential reason could be the discordance between lay and medical explanatory models of hypertension and its treatment. Understanding community perceptions and practices may contribute to improving hypertension control as they present insights into psychosocial and cultural factors that shape individual behaviour. We explore community perceptions regarding hypertension and its treatment in rural northern Ghana and how they differ from medical understanding.DesignThis was a qualitative study using semi-structured interviews and focus group discussions to collect data, which were analysed using a thematic approach.SettingA multisite study conducted in four rural communities in two regions of northern Ghana.ParticipantsWe conducted 16 semi-structured interviews and eight focus group discussions with community leaders and members, respectively.ResultsThree major themes were identified: community perceptions, treatment options and community support for people with hypertension. Community perceptions about hypertension include hypertension perceived as excess blood in the body and associated with spiritual or witchcraft attacks. Traditional medicine is perceived to cure hypertension completely with concurrent use of biomedical and traditional medicines encouraged in rural communities. Community members did not consider themselves at risk of developing hypertension and reported having inadequate information on how to provide social support for hypertensive community members, which they attributed to low literacy and poverty.ConclusionThere is a substantial mismatch between communities' perceptions and medical understanding of hypertension and its treatment. These perceptions partly result from structural factors and social norms shaped by collective processes and traditions that shape lay beliefs and influence individual health behaviour. Socioeconomic factors also thwart access to information and contribute to inadequate social support for persons with hypertension. These findings highlight the need for a public health approach to hypertension control targeting families and communities.

Project description:BackgroundThe shortage of formal health workers has led to the utilization of Community-Based Health Volunteers (CBHV) to provide health care services to people especially in rural and neglected communities. Community-based health volunteers have been effective partners in health care delivery at the community level for many years. The challenge is how to retain these volunteers and also sustain their activities. This study explored factors affecting retention and sustainability of community-based health volunteers' activities in a rural setting in Northern Ghana.MethodsThis was a qualitative study comprising thirty-two in-depth interviews (IDIs) with health volunteers and health workers in-charge of health volunteers' activities. Purposive sampling technique was used to select study participants for the interviews. The interviews were transcribed and coded into themes using Nvivo 10 software. The thematic analysis framework was used to analyze the data.ResultsStudy participants reported that the desire to help community members, prestige and recognition as doctors in community mainly motivated them to work as health volunteers. Lack of incentives and logistical supplies such as raincoats, torch lights, wellington boots and transportation in the form of bicycles to facilitate the movement of health volunteers affected the work. They suggested that lack of these things discouraged them from working as health volunteers. Most of the dropout volunteers said lack of support and respect from community members made them to stop working as health volunteers. They recommended that community support, incentives and logistical supplies such as raincoats, torch light, wellington boots, bicycles, awards to hard working volunteers are mechanisms that can help retain community-based health volunteers and also sustain their activities.ConclusionProviding means of transport and non-monetary incentives would help to retain community-based health volunteers and also sustain their activities at the community level.

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:Inadequate care during early childhood can lead to long-term deficits in skill development. Parenting programs are promising tools for improving parenting practices and opportunities for healthy development. We implemented a non-masked cluster-randomized controlled trial in rural China in order to assess the effectiveness of an integrated home-visitation program that includes both psychosocial stimulation and health promotion at fostering development and health outcomes of infants and toddlers in rural China. All 6-18 month-old children of two rural townships and their main caregiver were enrolled. Villages were stratified by township and randomly assigned to intervention or control. Specifically, in September 2015 we assigned 43 clusters to treatment (21 villages, 222 caregiver-child dyads) or control (22 villages, 227 caregiver-child dyads). In the intervention group, community health workers delivered education and training on how to provide young children with psychosocial stimulation and health care (henceforth psychosocial stimulation and health promotion) during bi-weekly home visits over the period of one year. The control group received no home visits. Primary outcomes include measures of child development (i.e. the Bayley Scales of Infant and Toddler Development, third edition-or Bayley-III) and health (i.e. measures of morbidity, nutrition, and growth). Secondary outcomes are measures of parenting practices. Intention-to-treat (ITT) effects show that the intervention led to an improvement of 0·24 standard deviations (SD) [95% CI 0·04 SD-0·44 SD] in cognitive development and to a reduction of 8·1 [95% CI 3·8-12·4] percentage points in the risk of diarrheal illness. In addition, we find positive effects on parenting practices mirroring these results. We conclude that an integrated psychosocial stimulation and health promotion program improves development and health outcomes of infants and toddlers (6-30 month-old children) in rural China. Because of low incremental costs of adding program components (that is, adding health promotion to psychosocial stimulation programs), integrated programs may be cost-effective.

Project description:BACKGROUND: The potential for community health workers to improve child health in sub-Saharan Africa is not well understood. Healthy Child Uganda implemented a volunteer community health worker child health promotion model in rural Uganda. An impact evaluation was conducted to assess volunteer community health workers' effect on child morbidity, mortality and to calculate volunteer retention. METHODOLOGY/PRINCIPAL FINDINGS: Two volunteer community health workers were selected, trained and promoted child health in each of 116 villages (population ?61,000) during 2006-2009. Evaluation included a household survey of mothers at baseline and post-intervention in intervention/control areas, retrospective reviews of community health worker birth/child death reports and post-intervention focus group discussions. Retention was calculated from administrative records. Main outcomes were prevalence of recent child illness/underweight status, community health worker reports of child deaths, focus group perception of effect, and community health worker retention. After 18-36 months, 86% of trained volunteers remained active. Post-intervention surveys in intervention households revealed absolute reductions of 10.2% [95%CI (-17.7%, -2.6%)] in diarrhea prevalence and 5.8% [95%CI (-11.5%, -0.003%)] in fever/malaria; comparative decreases in control households were not statistically significant. Underweight prevalence was reduced by 5.1% [95%CI (-10.7%, 0.4%)] in intervention households. Community health worker monthly reports revealed a relative decline of 53% in child deaths (<5 years old), during the first 18 months of intervention. Focus groups credited community health workers with decreasing child deaths, improved care-seeking practices, and new income-generating opportunities. CONCLUSIONS/SIGNIFICANCE: A low-cost child health promotion model using volunteer community health workers demonstrated decreased child morbidity, dramatic mortality trend declines and high volunteer retention. This sustainable model could be scaled-up to sub-Saharan African communities with limited resources and high child health needs.

Project description:BackgroundIn parallel with the change of malaria policy from control to elimination and declines in the malaria burden in Greater Mekong Sub-region, the motivation and social role of malaria volunteers has declined. To address this public health problem, in Myanmar, the role and responsibilities of malaria volunteers have been transformed into integrated community malaria volunteers (ICMV), that includes the integration of activities for five additional diseases (dengue, lymphatic filariasis, tuberculosis, HIV/AIDS and leprosy) into their current activities. However, this transformation was not evidence-based and did not consider inputs of different stakeholders. Therefore, qualitative stakeholder consultations were performed to optimize future malaria volunteer models in Myanmar.MethodsSemi-structured interviews were conducted with key health stakeholders from the Myanmar Ministry of Health and Sports (MoHS) and malaria implementing partners to obtain their perspectives on community-delivered malaria models. A qualitative descriptive approach was used to explore the experiences of the stakeholders in policymaking and programme implementation. Interview topic guides were used during the interviews and inductive thematic data analysis was performed.ResultsWhile ICMVs successfully provided malaria services in the community, the stakeholders considered the ICMV model as not optimal and suggested that many aspects needed to be improved including better training, supervision, support, and basic health staff's recognition for ICMVs. Stakeholders believe that the upgraded ICMV model could contribute significantly to achieving malaria elimination and universal health care in Myanmar.Discussion and conclusionIn the context of high community demand for non-malaria treatment services from volunteers, the integrated volunteer service package must be developed carefully in order to make it effective in malaria elimination programme and to contribute in Myanmar's pathway to universal health coverage (UHC), but without harming the community. An evidenced-based, community-delivered and preferred model, that is also accepted by the MoHS, is yet to be developed to effectively contribute to achieving malaria elimination and UHC goals in Myanmar by 2030.

Project description:BackgroundOver the past decade, global health policy has increased its focus on measures to halt further increase in tuberculosis (TB) incidence and management of diabetes mellitus (DM). However, the vertical management of these two diseases have not achieved much in addressing the adverse effects of the rising tuberculosis-diabetes co-epidemic. This necessitated the World Health Organisation and the International Union Against Tuberculosis and Lung Disease to develop a framework to manage this dual disease burden. TB-DM co-epidemic is a public health concern in Ghana, adversely threatening the country's fragile health systems. Since frontline healthcare workers are critical in health policy implementation, this study used Lipsky's theoretical framework of street-level bureaucracy to explore their experiences in implementing the collaborative framework at the health facility level in Ghana.MethodsThis qualitative study was conducted between July to September 2019 using an exploratory design. Data was generated using a semi-structured interview guide designed to elicit information on knowledge of TB-DM comorbidity as well as systems for co-management. Twenty-three in-depth interviews were conducted among purposively selected frontline healthcare workers (doctors, nurses, TB task- shifting officers, TB institutional coordinators and hospital managers) from three health facilities in the Northern Region of Ghana. The lead author also conducted observations and document reviews, in order to fully address the study objectives. Thematic analysis was guided by the Lipsky's theoretical framework of street level bureaucracy.ResultsThe findings revealed three main themes and six sub-themes. Main themes were Prioritisation of TB/HIV co-infection while negating TB-DM comorbidity, Poor working conditions, and Coping mechanisms, whereas sub-themes were Low knowledge and awareness of TB-DM comorbidity, Limited awareness of the collaborative framework, High workload in TB & DM Clinics, Multiple roles, Inadequate training, and Space shortage.ConclusionsFrontline healthcare workers had limited knowledge of TB-DM comorbidity and the collaborative framework, which, in turn adversely affected the effectiveness in implementing the framework. The effective implementation of the framework begins with raising awareness about the framework through in service training amongst the frontline healthcare workers. Additionally, an integrated screening tool to detect both TB and DM would help achieve early detection of TB-DM comorbidity.

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Valuing and Sustaining (or Not) the Ability of Volunteer Community Health Workers to Deliver Integrated Community Case Management in Northern Ghana: A Qualitative Study.

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