This qualitative comparative study aimed at understanding similarities and differences in how relationships between community health workers, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and community health workers’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between community health workers and the health sector resulted in weaker relationships between community health workers and communities. The broader context and programme context in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust community health worker programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling community health workers to perform well and responding to the opportunities offered by their unique intermediary position.
Human Resources
This qualitative formative research study aimed to inform the design of interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, the authors aimed to determine what leads to improved performance of CHWs. The CHW cadres studied were the rural health motivators, mothers-to-mothers mentors, HIV expert clients, and a community outreach team for HIV. Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: increased monetary compensation of CHWs, a more reliable supply of equipment and consumables, additional training, and an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as key factors.
From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and prevention of mother-to-child transmission services in Dar es Salaam, Tanzania. Slightly over half of the providers were dissatisfied with their current job, and 35% intended to leave it. Most providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The following factors were associated with providers’ intention to leave their current job: dissatisfaction at not being recognized by one’s superior, and poor feedback on the overall unit performance. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback are argued to be key to retaining satisfied health workers for prevention of mother-to-child transmission providers.
One way of improving health globally is promoting mothers’ adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. The challenge is how to promote learning and behaviour change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong. In addressing that challenge, a new learning/teaching method called “Sharing Histories” is in development to improve the performance of female community health workers in promoting mothers’ behaviours for maternal, neonatal and child health. This method builds self-confidence and empowerment of community health workers in learning sessions that are built on guided sharing of their own memories of childbearing and child care. Community Health Workers can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing community health workers programs. The author presents the Sharing Histories method, describes how it differs from other social and behaviour change methods, and discusses selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower Community Health Workers to be more effective change agents with other mothers in their communities.
This paper explores knowledge levels of community health workers (CHWs), describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy in eastern Uganda. The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The visits aimed to promote birth preparedness and utilization of maternal and newborn health (MNH) services. CHWs’ knowledge of MNH improved after training. However, knowledge of new born danger signs declined after a year. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57% and CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and maintained low dropout rates at 3.6%. Their challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of a means of transport, such as bicycles.
This study identified the level of knowledge and competencies related to quality of care during medical education in sub-Saharan African medical schools. A cross-sectional study design was utilised to examine the capacity of medical schools in sub-Saharan African countries to teach about the concepts of quality of care and the inclusion of these concepts in their curriculum. A purposeful convenience sampling technique was used to select participants from 25 medical schools in 5 sub-Saharan African countries. Respondents included medical school deans or senior academic personnel. While 45% of the schools surveyed are teaching on at least one of the six domains of the Institute of Medicine’s definition of quality of care, there are some schools who report not teaching about quality at all, or that they “do not know”. Despite these low numbers, when asked about topics related to quality of care, many schools are teaching applied management related topics and almost all schools teach about equity and patient-centred care. The results have implications for incorporating quality of care in medical education and for practitioners. The tool developed for this study could be used in future qualitative and quantitative studies to further understanding of how to improve the teaching and learning about quality of care in medical schools.
The nature of patient–provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient–provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, the authors seek to unpack local dynamics that serve to hinder or facilitate productive patient–provider interactions. This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. The authors analysis revealed an array of inter-related contextual factors and power dynamics shaping patient–provider interactions. These included participants’ perceptions of roles and identities of ‘self’ and ‘other’; conformity or resistance to the ‘rules of HIV service engagement’ and a ‘patient-persona’; the influence of significant others’ views on service provision; and resources in health services. They observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure. They argue that patient–provider interaction is complex, multidimensional and deeply embedded in wider social dynamics, and that interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient–provider communication strategies.
Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the difficulty in retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians, medical licentiates, trained initially to the level of a higher diploma and from 2013 up to a Bachelor of Science degree. Medical licentiates have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. This qualitative study aimed to describe the role, contributions and challenges surgically active medical licentiates have experienced. Based on 43 interviewees, it includes the perspective of medical licentiates, their district hospital colleagues—medical officers, nurses and managers; and surgeon-supervisors and national stakeholders. In Zambia, medical licentiates play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with medical officers, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, medical licentiates often face professional recognition problems and tensions around relationships with medical officers that impact their ability to utilise their surgical skills. The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if medical licentiates are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use non-physician clinicians to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
Uganda’s national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, the authors examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. The authors reported on findings from a standardised survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda. A mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged. VHTs desire additional support primarily in the forms of money (for example transportation allowance) and material supplies (for example rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health centre staff and greater ease in home visiting. The authors note that supporting and retaining Uganda’s VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.
Studies have shown the contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in in resource-constrained settings. The Support, Train and Empower Managers study designed and implemented a supportive supervision intervention and measured its’ impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.